Cash Docs

A trend that is gaining steam and creating a divide is doc's that shun health insurance in favor of cash.

Let's face it. Dependence on health insurance is over the top. Do you really need to pay an insurance carrier to cover expenditures less than $500? If so, you have bigger issues of concern.

Some medical practices are limiting or even refusing insurance payments in favor of cash paid direct by the patient.

Lower overhead is a benefit. Easy access to health care is another.

Though data on private practices is scanty, a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.

NY Times, "When doctors refuse insurance"

50%? Ouch.

But, but, but what about all those newly insured patients with their shiny new Obamacare cards?

Cash-only practices may exacerbate the access problem. Since her doctor stopped accepting her insurance, Kathryn Vanasek, 43, a mother of two in Manhattan, hasn’t been back for a checkup or preventive screenings, relying on a new walk-in clinic for urgent problems like an ear infection.

Her annual physical would cost at least $250 out of pocket, Ms. Vanasek said, but she would not get any money back from her insurer until she met the deductible.

How is that possible?

All legitimate major medical plans were required to offer "free" preventive checkup beginning over a year ago.

Will the concept of cash only doc's continue to grow as projected? Time will tell.

I was told there'd be no math

So what do these three (seemingly disparate) groups have in common:

■ People in prison
■ People living below the poverty line
■ Illegal immigrants

Give up?

"In just 14 months, Americans will be required to prove that they have federally "qualified" health insurance or face an [ObamaTax] of $695 to $2,085"

Well, most Americans. The folks comprising the three groups listed above are exempt (Sorry, Mags). And when taken as a whole, they represent over 16% of the people who live here.

They have something else in common, as well: they're the folks who, directly or indirectly, gave us the ObamaTax.

How's that, Henry?

It's pretty simple, really: the #1 selling point of the train-wreck was that some 15% or so of us were uninsured for health care. Folks in jail have no need of insurance, since their care's on us. The poor already had a myriad of social safety nets in place (eg Medicaid, SCHIP, etc). And illegals get de facto free health care.

Take out these three groups, and you're left with a handful of Americans who were uninsured (and/or uninsurable), a problem easily fixed without upending 1/5 of our economy and forcing us into nationalized health care.

Gee, thanks bunches.

Cavalcade of Risk #169: Up & Running!

Ray at the Excess Return blog makes his CavRisk hosting debut with this edition, chock full of interesting posts and helpful recaps.

Well, at least it’s free…

A report from the Physician’s Foundation lays out a very grim picture of the future of medicine in America.

“Over half of physicians surveyed have reached a tippingpoint and plan to make changes to their practices. Many intend to take one ormore steps likely to reduce patient access to their services, limitingphysician availability at a time when doctors already are in short supply.”

This paragraph sums up medicine today:

“PRACTICE EROSION

Over the last half century or more, medicine has evolved from the province of solo and small group practitioners who contracted directly with patients, to an increasingly centralized profession in which treatment is paid for by third parties. Several decades ago, both Medicare and private insurance companies paid physicians retroactively for “usual, customary and reasonable charges,” meaning doctors typically received what they invoiced. This system has been repeatedly modified since, in an effort to reduce costs and manage care, often creating a disconnect between the services physicians provide or believe is appropriate and the services for which they are compensated. This trend may reach a culmination on January 1, 2013, when physicians are due for a 30 percent reduction of their Medicare reimbursement under Medicare’s Sustainable Growth Rate (SGR) formula.”

So physicians today are paid what the government says they should be paid.  The only option for a physician is to become non-participating with all insurance companies, concierge, or direct care, all of which are all cash paid basis for the patient.  This directly impacts a patient, as individuals are becoming more responsible for rising insurance premiums in conjunction with physicians moving away from the third party payment system.

Additionally, “the bar to professional entry for physicians keeps rising, with four years of college education, four years of medical school, and as many as seven years of residency training necessary for those who wish to sub-specialize. Medical education and training come at a high cost, as medical school graduates now carry an average of $156,456 in educational debt, according to the Association of American Medical Colleges (AAMC).”

“FLAGGING MORALE, PERVASIVE PESSIMISM

When asked which best describes their feelings about the current state of the medical profession, only 3.9 percent of physicians used the words “very positive,” while 23.4 percent of physicians indicated their feelings are “very negative.” The majority of physicians – 68.2 percent -- described their feelings as either “somewhat negative” or “very negative,” while only 31.8 percent of physicians described their feelings as “somewhat positive” or “very positive.”

“The great majority of physicians (84.2 percent) agree with that the medical profession is in decline…. Practice owners are more inclined to believe the medical profession is in decline than are employed physicians and specialists are more inclined to believe the medical profession is in decline than are primary care physicians.”

This attitude is pervasive in the medical community.  Physicians are working harder to make the same amount of money they made a decade ago.  Regulations are sapping physicians' time in unnecessary paperwork.

“There is no disputing that medicine is one of the most highly regulated of all professions, and that physicians must adhere to a vast array of laws and requirements imposed by the government and third party payers…. The Medicare regulatory code stipulating provisions by which physicians must abide is over 130,000 pages long.”

Costs such as EMR’s and staff are eating into an already thin profit margin.  Combined, these stressers are reflected in the survey in these findings:

“Over one third of physicians would not choose medicine if they had their careers to do over.”

“Over 60 percent of physicians would retire today if they had the means.”

“In the next one to three years, over 50 percent of physicians plan to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to their services.”

The exodus of doctors from the practice of medicine has begun and the nations brightest and best are no longer interested in a career in medicine.  The high caliber of medicine in America, which was developed through the free market of capitalism, has been brought to the level of mediocrity.  Well, at least it will be free.

More on that 3000% ObamaTax insurance rate decrease [UPDATED]

Not. Happenin'.

From United Health One (formerly Golden Rule) email:

"We will no longer provide our initial 12-month rate guarantee for plans with January 1, 2013 or later effective dates to allow for required changes resulting from the [ObamaTax]."

Ooops.

UPDATE: And the Cato Institute's Michael Cannon reports that the Golden State will see its citizens' insurance premiums shoot up some 25% as a result of the ObamaTax Exchange scheme:

"Under a new rating map approved by state lawmakers, the Department of lnsurance estimated that premiums for similar coverage could increase as much as 25% in West Los Angeles, 22% in the Sacramento area and nearly 13% in Orange County."

Ooops, indeed.

HWR under the 'scope

So it appears that I wasn't the only one underwhelmed by last week's Health Wonk Review: The Disease Management Care Blog's Jaan Siderov was also unimpressed with (his term) Hurricane Maggie's "efforts."

Here's a taste:

"Hurricane Maggie repetitively retreads the cost-control talking points from reform architect Peter Orszag, surgeon Golden Boy Atul Gawande and the White House Office of Management and Budget ... The DMCB says value remains an inexact science that is ill-suited to simplistic nostrums and blunt force laws and regulations."

Indeed.

Go read the whole thing (a few minutes well-spent).

Bad News for Buckeyes

The ObamaTax is gonna hit us in the wallet, and the waiting room:

"A non-partisan study found that, by 2017, individual premiums in Ohio will increase by as much as 85 percent. In addition, Obamacare will deeply cut Medicare Advantage for more than 700,000 Ohio seniors enrolled in the program. And more than 30 percent of Ohio physicians say that they will place new or additional limits on accepting Medicare patients."

We've already seen major rate increases, although it's not fair to lay the blame entirely on the ObamaTax. Health care costs drive health insurance costs, and these are influenced in part by utilization and medical inflation. Still, it's undeniable that at least a chunk of these increases can be laid at the feet of the train-wreck.

Medicare Advantage plans, which actually help rein in some health care costs and offer our seniors choice in health care, have been on the proverbial chopping block for a while; it's no surprise that the ObamaTax will decimate that market.

And of course regular IB readers have known about the coming provider shortage for a while now.

[Hat Tip: Bob Vineyard]

And now for something completely different...

If you are interested in the relationship of science, religion and current events, you might want to check out a new blog by a good friend (and mentor) of mine, Dr Stuart Fickler.

Called the "Secular Kabbalist," Stuart has a Ph.D.in theoretical physics, and "is dedicated to exploring the complementary relationship between religion and science, and its impact on the realities of today."

From one of his most recent posts:

"Humanity has lived under an illusion.  Many believe that we have unlimited independence of choice.  Reality demonstrates otherwise ... The universe is a system.  Everything in it is connected by fields, such as gravity, electromagnetism, etc.  Nothing changes in the universe without the entire universe being affected."

Heady stuff, to be sure, but quite accessible. Recommended.

This Sceptered Isle - Part CLXXXIV [UPDATED]

"Caroline Cassin, 29, who suffers from Cystic Fibrosis (CF) has been offered a new drug free of charge for a limited period by the makers but her NHS hospital is refusing."

Why would that be?

One must read to the very end of the article  to find out.

"The trust decided not to obtain Kalydeco on a compassionate basis because the drug company scheme is temporary and the trust would face withdrawing the medication when the scheme stops."

So is the issue how best to provide life-preserving patient care?  Is the issue how to save money for the NHS hospital trust?  Is the issue how to protect the hospital trust from political fallout?

Whatever the answers, I think this is how so-called "death panels" work in real life.  They don't march in and command "off with your head".  Instead, they work quietly, in private; they employ trusted physicians and other medical professionals under the authority of government who decide whether to block certain types of medical care from certain patients.  This saves money without the ugly and potentially distasteful public task of later having to withdraw that medical care from the unfortunate patients.  

Innocuous . . . really.  And fair.  Right?

UPDATE [We get results!]:

"Medical Director for Heart of England NHS Foundation Trust, said: “Since our last statement we have continued discussions with the company Vertex who produce the drug Kalydeco.

 Following these discussions, we are very pleased to announce that they have taken the decision to offer the treatment on a compassionate basis to named patients, without limiting the offer to a fixed period of time."

Removing the time limit means the hospital (Trust) will not face public calumny on account of withdrawing the treatment at the end of some fixed treatment period.

Ironic, isn't it, that public calumny was necessary to move the hospital trust - and the drug maker - to this decision?

Also worth noting that public opinion still counts for something - even in a quasi-socialist nation like UK.

Not What it Seems

Bob posted about a woman who was charged for “asking too many questions.”  The article in question is about a woman, Susan Krantz, a registered nurse who was confused by her bill. The article's title - "Questions can trigger split charge" - is misleading, as no one is charged for asking too many questions.  What happened in her case is that she went in for a wellness visit and then asked the doctor about a problem, a sore hip.  At that point the visit went from a regular wellness visit to a sick visit or as the article points out, “an “acute care” matter.”

By current policy, there is no charge, referred to as co-pay or out of pocket expense, on an annual wellness visit.  What is misunderstood is that once a person brings up an acute care issue, such as an injury or illness, or if in the course of the exam the physician discovers an acute care issue, such as a lump or other malady, and then the appointment becomes a sick visit and is billed accordingly.  This billing is subjected to a deductible and co pay, which is the patient’s responsibility.  CMS defines a wellness visit as:

As of 2012, the annual wellness visit benefit includes the following services:

■ Routine measurements, such as your height, weight, blood pressure, and body mass index (BMI);
■ Review of your individual medical and family history;
■ Review of the medications, supplements, and vitamins that you are currently taking;
■ Discussion of the care you are currently receiving from other health care providers;
■ Review of your functional ability and level of safety (for example, your risk of falling at home), including any cognitive impairment, as well as a screening for depression;
■ Discussion of personalized health advice that takes into account your risk factors and specific health conditions or needs, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition;
■ Discussion of referrals to other appropriate health education or preventive counseling services that may help you minimize or treat potential health risks;

This list does not include care for acute problems, such as the sore hip brought up by Ms. Krantz.

The article states, “In a written statement, the medical provider said that “the insurance company may require that patients pay or make a co-pay for services beyond the ‘preventive’ part of the appointment.”  The moral of this story is that in the end the patient is responsible for the consequences of any medical appointment with a medical provider, so be prepared.

Yikes! Obamacare Is Even More Unpopular Now than in 2010 [UPDATED]

"Americans support [PPACA] repeal by an even wider margin than they did in the immediate aftermath of its highly unpopular passage ... by a margin of 15 percentage points (54 to 39 percent), likely voters now support the repeal of President Obama’s centerpiece legislation.  In the first three polls taken in the wake of the House’s passage of Obamacare (on March 21, 2010), Rasmussen showed that likely voters then favored repeal by margins of 13 points (55 to 42 percent), 12 points (54 to 42 percent), and 12 points (54 to 42 percent)"

I seem to recall a time when the political leadership claimed that they had to pass PPACA so that we can find out what is in it. 

We are finding out.  The apparent result is this steadily growing opposition.  

Fail. BIG fail.

UPDATE [From HGS]: To get an idea why this plan is so hated, here's a link to an interactive timeline of its implementation. Notice that the plan we had to "pass to learn what's in it" comprises over 50 "checkpoints," from Adoption Assistance to taxes on "Mercedes" "Cadillac" plans.

Medicare Open Enrollment 2012

What you need to know about Medicare open enrollment 2012. How to save money. Should you change plans or find a new one? Avoid rate increases. Get the help you need. Make good choices.

Choices for Medicare Open Enrollment 2012

Medicare consumers "ride out the price increases," Walters adds. "They don't do the math. They are worried that their doctors won't be covered under a new plan ... People bog down in indecision because they're scared they are going to make a mistake." While many things change about Medicare each year, Walters says, "the only thing that doesn't change under Medicare is that it continues to be complicated."

US News, "Medicare Open Enrollment"

Medicare supplement plans don't have networks. You never have to worry about changing doctors with original Medicare and a Medigap plan.

During Medicare open enrollment, Many Medicare Advantage plans are handing out significant rate increases coupled with extreme increases in copay's and out of pocket expenses. Many Georgia Medigap plans will pass out rate increases in January, some may be 15% or more.

Some carriers have never raised rates more than 9%.

Lock in current low rates now and avoid the January rate increase.

Medicare Open Enrollment - Medicare Part D - Choose Wisely

Some existing Part D plans will have significant premium increases. Average Part D premiums for current plans will increase by 6 percent in 2013, according to an analysis of Centers for Medicare and Medicaid Services data by Avalere Health, a healthcare consulting company. "Some of the more popular plans from the past have higher premiums, so people would be well-advised to take a look at their options to see if they can save money by switching into a new plan,"

US News, "How to pick Medicare Part D"

Medicare Part D is time consuming and confusing. Some agents are glad to assist current clients in finding the right plan for their needs and budget. This is a value added service for their existing clients. Often they are not compensated in any way for this assistance.

Many agents will only show you plans with carriers that have appointed them and pay for referrals. With more than 50 plans in some areas, why limit your choice to only plans where an agent will be paid?

Medicare Open Enrollment - Changes for 2013

There are new preventive services available next year to include:
■Alcohol misuse counseling
■Cardiovascular disease counseling
■Depression screening
■Obesity screening and counseling
■Sexually transmitted infections screening and counseling
Another important area for change in 2013 is if you reach the ‘donut hole’ in your Medicare Part D prescription drug plan, you only have to pay 47.5% for covered brand-name drugs and 79% of the costs for generic drugs until you reach the end of the coverage gap. Remember that out of pocket expenses like your annual deductible (if you have one) coinsurances, copayments and what you pay in the coverage gap will count toward getting you out of the coverage gap.

Fox News, "Boomers Guide to Medicare Open Enrollment"

Consider changing to generics which will save money and possibly keep you out of the donut hole in 2013.

The "Public Option" Lives

It's that time of year when the airwaves are flooded with zombies and other assorted monsters. So it should come as no surprise that the long-thought-dead Public Option has been given new life under the ObamaTax:

"The [Obamastration] will soon take on a new role as the sponsor of at least two nationwide health insurance plans to be operated under contract with the federal government and offered to consumers in every state."

After all, who needs an Exchange when we can just cut out the middleman and go directly ro government-run health insurance? These plans will "compete" with commercial insurers, but it's not exactly a level playing field: how can private companies compete with the Federal leviathan?

The simple answer is: they can't.

It's an expansion of the Federal Employees' health plan, which has worked so well in reining in health care and insurance costs. Since these plans will be subject to regs from at least three different agencies, good luck resolving claims or other issues. Which then brings us to the role of the National Association of Insurance Commissioners (NAIC). That august body "expressed alarm at the prospect of a double standard." I'm sure the Feds will get right on that.

It's interesting timing, as well, since President Obama has decided to discontinue vital health care services for our veterans. Is there a message in this?

Methinks you already know the answer to that.

Veteran's October Surprise

With election day less than 2 weeks away the "October surprise" may take on a different twist this year.

It looks like the announcement of the controversial move to discontinue TRICARE Prime for military members and their families in certain states, though, will wait until after Election Day.

As first reported by Military Times, starting April 1 TRICARE Prime services would be offered only to those living within 40 miles of a Military Treatment Facility as a result of the incoming contractor, United Healthcare, not planning on covering the services.

This would affect as many as 30,000 veterans and their families in Nevada, Oregon, Iowa, Minnesota, and Missouri. While those outside of an acceptable distance from an MTF wouldn’t lose coverage, they would be reduced to the standard plan that carries higher out-of-pocket costs.

PJ Media, "Pentagon waits to tell Vet's they may lose health coverage"

The announcement will wait until after election day.

Probably just a coincidence . . .

But then you must remember that the president was a big fan of the WARN Act until he discovered it may impede his chance for re-election.

Thanks to Henry Stern for this tip!

Sandy App

For those in the path of Hurricane/TS Sandy (and/or for those who may face other severe weather conditions) the Insurance Information Institute has a cool - and helpful! - app for disaster preparedness. From email:

"The I.I.I.’s “Know Your Plan” app for iPhone provides users with a library of preloaded checklists to guide them through important property protection and preparedness steps. These include specific lists to help prepare for hurricanes, floods and winter weather—the very conditions threatened by Hurricane Sandy, which may turn into a hybrid “perfect storm” with high wind, heavy rain, extreme tides and maybe snow."

You can download the app from iTunes.

Let's play Guess Who?

OK sports fans, here are three paragraphs from an interview with a brilliant and well-known college professor.

I’m quoting these paragraphs here only because in the course of the interview - which is mostly focused on other things - the conversation eventually comes around to ObamaCare.  And then the professor really lets loose.

Aside from the interesting points made about ObamaCare, my question is:  based on the following three paragraphs, can you name the professor?

“. . . Obamacare: of course, we need health care reform in this country. What a mess! Everyone agrees about that. But the Obamacare is, to me, a Stalinist intrusion — okay? — into American culture.”

“You don't want government agencies being empowered to intrude into people's lives like this. The controlling force in Obamacare is the IRS! Okay? This flies in the face of what the Free Speech Movement was about at Berkeley or about any of the values, I feel, of my generation.”

“I don't see progressives. All I see is white upper-middle-class liberals who speak in this unctuous way about the needs of the poor.  They have no connection whatever with the working class. Okay? It's the professional class gone amok. And that's why they don't notice what a bureaucratic nightmare Obamacare is.“

Here is the source.  I think many readers will be surprised.

(The ObamaCare remarks begin at 12:38)

Show me the [Pounds Sterling]

My first reaction on reading the following was disbelief at the incredible cynicism inherent in the Much Vaunted National Health System©. But then I recalled this and it began to make sense:

"Hospitals are paid millions to hit targets for the number of patients who die on the Liverpool Care Pathway ... In some cases, hospitals have been set targets that between a third and two thirds of all the deaths should be on the [Pathway]"

Yes, you read that correctly: the MVNHS© has actually begun (continued?) to set death quotas. When one considers the ObamaTax Independent Payment Advisory Board Death Panel, it doesn't seem like much of a stretch to see this idea taking hold here.

The rationale, of course, is that killing patients denying treatment is an efficient cost-savings measure. Turns out, though, not so much:

"At least £30million [about half a million dollars] in extra money from taxpayers is estimated to have been handed to hospitals over the past three years"

That's quite an incentive to shunt folks off the care line, no? And recall that "[m]edicine has always been more of an art than a science," and it becomes increasingly clear just how easy - and profitable - it becomes to just pull the plug.

Fortunately, only a very few folks end up on there, right?

Sorry:

"LCP is thought to be used in more than 100,000 cases a year"

Ouch.

Health Wonk Review: Pre-election edition(s)

Maggie Maher hosts an unwieldy and, ultimately, unsatisfying HWR this week. As a long-time participant and supporter, I feel obligated to link to it but I cannot recommend clicking through.

My understanding of, and experience with, hosting an edition of the Health Wonk Review is that one chooses which posts to include, along with a (brief) description. Sometimes, a snide or supportive remark by the host is warranted, but Maggie gives vent to full blown diatribes about several of the entries. I find this disconcerting and, frankly, off-putting.

Intriguing Carrier Idea

We've written before about Critical Illness (CI) policies. These plans pay one a lump sum upon diagnosis of a specific major illness or other similar kind of medical issue (transplants, permanent paralysis, that kind of thing). They're relatively inexpensive, and can provide a much needed transfusion of cash, especially if one has a high deductible plan (such as an HSA).

Humana's taking this a step further, bundling their CI plan with their group HSA products:

"[E]mployees receive a benefit after a serious illness, condition, or accident. During their recovery, they and their loved ones can rest a little easier knowing they won’t have to rely solely on their savings accounts or take on additional debt to cover day-to-day living expenses." [ed: from email, so no link]

Pretty clever (keeping in mind, of course, that the ObamaTax wipes out HSA's in the near future).

[Hat Tip: Cornerstone]

Cavalcade of Risk #169: Call for submissions

Ray at Excess Return hosts next week's Cavalcade of Risk - Entries are due by Monday (the 29th).

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

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.

Thanks!

Is Medicine an Art or a Science?

My oldest daughter was born with several health issues; a cleft palate, low muscle tone, windswept feet, and jaundice.  As new parents, my husband and I were beside ourselves on how to care for our new baby.  We were lucky to find a pediatrician who calmed our fears while offering great care to our daughter.  A piece of advice that he gave me is that he trusts a mother’s intuition regarding her children; in other words, if a mother thinks something is wrong with her child, she is usually right.  I have used that philosophy for the past 23 years in raising our daughter and two other children and it has always proven accurate. 

Health Day has recently reported on a study regarding intuition:

“Doctor’s intuition that something is seriously wrong may have more diagnostic value than many symptoms and signs, the report suggested.  Parental concern that a child's illness was differentthan normal was another strong influence on gut feeling, the study authorsnoted in a journal news release.  A gutfeeling should prompt doctors to conduct a full and careful examination, seekadvice from a more experienced doctor, and advise parents what to do if theirchild's condition worsens, the researchers concluded.”

Doctor’s use experience as well as education to treat patients.  Medicine has always been more of an art than a science.  Today, however, there is a push to make medicine a science, removing all subjective processes from t he experience.  It is a push under the title of “Medical Necessity”.  Medical Necessity has been pushed by the government for the past few years to have doctors use tests and past performances to treat a person.  Now private insurers are jumping on the bandwagon.  United Healthcare recently released a notice that it would implement Medical Necessity in inpatient care beginning Oct. 1:

“As a reminder, Medical Necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. The Medical Necessity process is based upon a foundation of evidence-based medicine and:

·  Provides an opportunity to address covered services at the individual level to support enhanced access to quality care for the member.

·  Utilizes generally accepted standards of good medical practice in the medical community.

·  Offers timely communication between health plans, members and providers to allow for prospective, concurrent and retrospective review as well as appeal rights for adverse determinations.

This foundation supports United Healthcare’s overall goals for providing enhanced access to quality care by raising performance standards and reducing variation in medical practice, and health care affordability by implementing a process that promotes efficient delivery of high-quality care in a cost-effective manner.”

What is important to note in this missive is the sentence: “The Medical Necessity process is based upon a foundation of evidence-based medicine.”  Evidence-based medicine is defined as "treatment based on tests, labs and best medical practices for the medical condition."  The problem is that diagnosing based on tests and labs is easy for the obvious conditions, such as a broken arm or an ulcer, but as a doctor once remarked to me “you cannot see pain on an x-ray”.  In other words, not all medical problems can be determined from a test or lab.  There are many anecdotal examples of doctor’s misdiagnosing or missing a serious problem, even with tests.  This was brought to attention recently in an article in the Daily Mail about a woman who died from undiagnosed cervical cancer.

If physicians will now only be paid for evidence based medicine, then many diagnoses that are being paid for today - such as chronic fatigue syndrome, depression, or low muscle tone, which cannot be determined by a test but instead by direct observation and physician expertise - will no longer be viable diagnoses.  At the end of the day, as much science as there is in medicine today, it is an art and art cannot be measured.

Medigap not evil?

When they're not screwing up consumers' life insurance choices, the National Association of Insurance Commissioners (NAIC) does try to do positive things. For example, they have a whole committee that's been working to strengthen support of Medicare supplement plans that limit beneficiaries' out of pocket expenses.

The Senior Issues Task Force [ed: good thing they didn't add "Health" in there] has been trying - thus far unsuccessfully - to communicate that message to HHS Secretary Shecantbeserious. Madame Kathy has "asked the NAIC to think about ways to change the NAIC's Medigap model regulation" to further reduce those out-of-pockets. The problem, of course, is that health care costs what health care costs, so someone is going to get stuck with a big bill.

Care to guess who?

Wednesday LinkFest: Dead Parrots and Deer Strikes

Assurant's Jeremy Fink tips us to the latest news from the Council for Disability Awareness (CDA), which recently released the results of its annual Long-Term Disability Claims Review. The review includes data from 17 member companies which participated in the 2011 survey. It's important to note that these 17 carriers represent about 75% of the private DI industry (giving cred to the results).

Some nuggets:

■ As a group, the carriers paid out over $9 billion in long-term disability claims (about 2% more than in 2010)

■ Over 95% of the claims were *not* work-related

■ This is troubling: for the third straight year, the number of covered lives decreased by a half of a percent, meaning fewer people were insured. I'm sure double-digit unemployment had nothing to do with that, of course.

You can read the whole report here.

FoIB Michael Cannon (who's also the Cato Institute's Director of Health Care Policy) continues his beat-down of the ObamaTax Exchanges, pointing out what he considers a fatal flaw:

"[T]he Democrats had no choice but to accept the Senate version. And that version is structured in such a way that individual states can decide to opt out of those state health insurance exchanges that are central to Obamacare."

And what's so insidious about that? For one thing, think of a dead parrot. And more taxes.

Finally, the Insurance Information Institute (III) reports that deer-vehicle mash-ups are increasing:

"An increase in urban sprawl and more roads being built through wildlife habitats have displaced deer from their natural habitat, leading to a rise in deer-vehicle collisions ... An estimated 1.23 million deer-vehicle collisions occurred in the U.S. between July 1, 2011 and June 30, 2012, costing more than $4 billion in vehicle damage"

And it's not just cars that get wrecked - these can be extremely dangerous for drivers and passengers, as well, killing some 200 people every year. So watch out for Bambi.

Open wide and say....

'Twas nice while it lasted.

I'm no fan of dental plans in general, so this news isn't exactly heart-breaking for me, personally. Still, it's one more nail in the "pro-choice" coffin:

"The [ObamaTax] could create a new divide between consumers who have high-end dental coverage and consumers who have bare-bones dental coverage, or no dental coverage at all."

That's according to a new study from the National Association of Dental Plans (kind of AHIP for the toothy crowd). The study claims that 60% of consumers surveyed had some sort of dental plan. Frankly, I find that number dubious, at best. On the other hand, it also claims that 53% of respondents had visited the dentist in the past 6 months. Maybe.

The issue at hand is that, since the ObamaTax essentially kills the employer-based health insurance market, it will wreak ancillary havoc on the dental one. This makes some sense: dental plans per se aren't directly affected by the train wreck, but that nasty Law of Unintended consequences can be a real toothache.

Obamacare HSA

If you read the law, the HSA (Health Savings Account) qualified health insurance plans will go away in 2014. The deductibles are too high, they don't have copay's, and most of them have much more out of pocket than the government says you should have.

But the folks in the cornhusker state have other ideas.

Nebraska Gov. Dave Heninemen sent a letter to HHS Sec. Sebelius asking for permission to offer HSA qualified plans through their state exchange.

Did you ever think the day would come when you would have to ask a non-elected official for permission to market health insurance? I didn't.

Heineman sent the letter more than two weeks after submitting an insurance plan with an $8,000 deductible for families as the minimum standard for individual and small group plans to be offered when the federal health care overhaul kicks in fully.

The high-deductible plan would be the benchmark for policies sold both inside and outside of the health insurance exchange to be created under the federal law.

Omaha.com, "Heineman wants to fund health accounts".

A thinking Republican governor. I like it.

In the letter, Heineman said his insurance proposal would reduce the federal government's cost for premium subsidies by keeping premiums lower.

“Consumers could better control their health care costs” if they have to pay more upfront, he added.

At the same time, Heineman said, a federal subsidy for health savings accounts would help people get their health care needs met and ensure that doctors, hospitals and other health care providers get paid.

Logical, fiscally sound arguments all around,

Probably doesn't stand a chance in DC.

(State Sen. Jeremy Nordquist) also questioned whether it would put health care in reach for many Nebraska families.

“For me, affordability is about how much does it cost to get you health care when you need it,” Nordquist said.

What good is it to have health insurance with low deductibles and low copay's if no one can afford the premiums. Just shows how out of touch most politicians are.

The government wants us to drive fuel efficient cars that get 60 MPG. Sounds great, but not if we have to pay double the current price of a car to get that kind of mileage.

Stop Talking

Susan Krantz was upset when she opened a recent bill. Along with the list of procedures was the itemized charge of $50.06 for something she couldn’t make out. When she questioned Park Nicollet, the response puzzled her.

“You can be charged an extra office visit if you ask too many questions,” she said. “I said I don’t understand that, because isn’t that what this visit is for?”

CBS Minnesota " Questions can trigger split charge"

Well shut my mouth!

How much time do we have? Well, the Medicare Trust Fund Disappears in just 3 presidential terms

The 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds was submitted April 23, 2012 to John Boehner and Joseph Biden, Speaker of the House and President of the Senate, respectively.  That report states (at page 6 et seq)

"The estimated exhaustion date for the HI trust fund remains at 2024, the same year shown in last year's report."  and

"HI expenditures have exceeded income annually since 2008, and projected amounts continue doing so through the short-range period until the fund becomes exhausted in 2024."

2024 may sound like a long way off in the future but it's only 12 years - 3 presidential terms.  That is not much time.

This is important stuff.  But if you prefer not to wade thru the Trustees Report, then please at least read this opinion piece in Sunday's Washington Examiner.

Here are two key paragraphs (but read the whole thing):

"Under Romney's plan, Medicare would not change for anyone who is currently 55 years of age or older. For those who are not yet 55, Romney has proposed a premium support program that puts the choice of health care coverage in the hands of seniors, not the government. If Medicare is the best option, future seniors will still have access to the program, but if there is a more affordable or higher quality plan in the private sector, older Americans will have the choice to leave traditional Medicare and pocket any savings.

"Whereas President Obama's top-down approach only lowers the amount the federal government will pay for services, Romney's proposal introduces competition into Medicare in order to drive down the cost of health insurance and provide an incentive to improve and innovate current plans for seniors."

I would only add that enabling private insurance competition for Medicare will be a good thing, but that is still nibbling around the edges of the more fundamental problem - the cost of delivering medical care in the U.S.  

Until that more fundamental problem is acknowledged and faced honestly, there is no real hope for a solution that works any better than the failed "solutions" of the past 45 years.  Those failed "solutions" have now brought us to within 3 presidential terms of a Medicare whose trust fund is exhausted and whose annual costs will continue to run far in excess of annual income.  In the private sector, that would be called "broke" if not "bankrupt".  In government work, it's called something else.  

But it walks like a duck and quacks like a duck . . .  So if this is not a crisis what is?  If now is not the time to tackle it, when will be?  If Americans will not devise a solution for ourselves, who do we think will come along and impose one on us?

Racking them up on the MVNHS©

As we've been documenting for many years (most recently, here), the Much Vaunted National Health System© is very good at one thing: killing off its victims patients. In fact, the "system" is pretty efficient at doing so:

"Patients having major surgery in [MVNHS©] hospitals face a much higher risk of dying than those in America ... seriously ill NHS patients were seven times more likely to die than their American counterparts."

W already knew that our cancer survival rates were many times better than the Brits', but this metric goes even further. It appears that a primary driver in this case is a shortage of specialists (which we're already seeing here as a result of the ObamaTax) and post-op facilities. This is rationing without rationale.

The study also posits that the long wait for treatment means less chance of a positive outcome, which drives up the mortality rates even more. Oh, you want to know how we stack up? No problem:

"The results showed that just under ten per cent of British patients died in hospital afterwards compared to 2.5 per cent in America. Among the most seriously ill cases there was a seven-fold difference in the death rates." (emphasis added)

Not for long.

[Hat Tip: Daniel Mitchell]

ObamaTax vs RomneyCare

Mike gave us a very cogent analysis of the actual, as-implemented MassCare plan, which was, in fact, much different than the original program set forth by Gov Romney. LifeHealthPro's Allison Bell offers her take on key differences between the two Presidential contenders' visions.

Here are a few examples; I really recommend that you read the whole thing:

"2. Women’s health and abortion"

Contrary to the spin, the ObamaTax does, in fact, include coverage for abortion [ed: please note that this is my take, not Ms Bell's]. And, of course, there's the whole convenience item birth control mandate.

Romney's plan doesn't (seem to) address either issue.

"5. Tort reform"

There's no mention of this in the ObamaTax, which doesn't preclude HHS Secretary Shecantbeserious from requiring it.

Romney proposes caps on "non-economic damages in medical malpractice lawsuits."

"6. Health accounts"

Regular readers know we're big fans of consumer-driven health care, which the ObamaTax effectively guts ("essential benefits," slashing of HSA's and FSA's, etc).

It's probably no surprise that Romney supports expanding these types of plans.

Ms Bell does a great job of thumb-nailing some of the key differences, including treatment of Medicare and Medicaid. Definitely worth clicking through.

If You Like Your Health Insurance Plan . . .

It all sounded so warm and fuzzy 4 years ago. My how time flies.         

The folks in and around DC are going to find their options somewhat limited due to the closure of the private health insurance exchange.

The D.C. Health Benefits Exchange Board unanimously approved closure of the private insurance marketplace for both individuals and small businesses, requiring them to purchase health insurance through a city-run exchange.

IFAwebnews, "DC to close private health insurance exchange"

Government run health insurance. What could possibly go wrong?

While a D.C. board subcommittee called the closure “market consolidation,” small business owners called it a drastic and unnecessary change to the marketplace.

Market consolidation.

A monopoly is still a monopoly  by any other name . . .

So DC, how is this working for you?

Liverpool not just for Beatles

We've discussed the Liverpool Death March Pathway before; in brief, the program's "being used to cut costs instead of as simply a more humane mode of care ... allows medical staff to withhold fluid and drugs in a patient’s final days."

Turns out, even this draconian  measure's not enough for the Much Vaunted National Health Service©:

"Thousands of patients have already been placed on 'death registers' which single them out to be allowed to die in comfort rather than be given life-saving treatment in hospital."

Some 3,000 health care "providers" enthusiastically participate in this (un)official death panel, which targets those victims patients who are expected to die within the year. Of course, one wonders whether there's a sort of synergy inherent in that process...

The program even has a very benign sounding title, "End of Life Care Registers," as if one were engaged or expecting a baby. Perhaps Harrods even has a department just for these folks, where one can pre-order coffins and the like for those "lucky" enough to make the list.

Not that the victims patients themselves would even know of it:

"Although more than 7,000 patients nationwide have already been put on the list, there appears to be no obligation for doctors to inform them."

Which I'm sure they're getting right onto.

What's so scary about this is the banality of the term "Register;" sounds ever so much more pleasant than Death Panel, don't you agree?

Checking up on Check ups

Are those "free" routine physicals over-priced? The WSJ's Shirley Wang reports that they may, in fact, be less helpful than one might believe:

"General medical checkups for healthy adults may not be as beneficial as people tend to think ... raising questions about whether spending on preventive services should be more focused on tests shown to be effective."

This doesn't mean, of course, that they're bad things, or will contribute to an early demise. But it appears that their actual effectiveness may be over-hyped.

One of the primary challenges is that we do love our "freebies," and any threats to curtail them are met with, well, certainly not enthusiasm. But the ObamaTax requires that they be covered in full, so of course there'll be a lot more of them (to the delight of Big Laboratory, one supposes).

Great.

[Hat Tip: FoIB Holly R]

Under the ObamaTax Hood

Behemoth tax and accounting firm Ernst & Young has put out a comprehensive study of exactly how the new ObamaTax fees penalties taxes will impact business (and anyone employed by a business). And it ain't pretty:

"[T]he employer community has reacted with concern to ...  the [ObamaTax's] Medicaid provisions, allowing states to decide whether to comply with the Medicaid expansion provisions without risk of losing existing federal funding ... In states that do not expand Medicaid, employers could face greater exposure to taxes for lower-wage employees who otherwise would have been eligible for Medicaid and may now be entitled to tax credits for Exchange coverage if their employer coverage is not affordable."

Onerous.

But it gets worse: new definitions of "large" versus "small" employers, seasonal versus part time or temporary employees, the employer mandate. All of these create uncertainty and, of course, higher costs of doing business (hiring and training HR personnel or conmsultants, increased tax planning, the list goes on).

But wait, it gets still worse:

"The law states that a plan shall not meet the minimum value determination if “the plan’s share of the total allowed costs of benefits provided under that plan is less than 60% of such costs.” How minimum value is determined will have a tremendous impact on the affordability and administration of employee benefit plans and is intricately intertwined with the other employer provisions."

Follow that?

Don't feel bad, it's going to be a bonanza for the CPA's and JD's.

Oh, one last bit:

"Even among employers who for decades have voluntarily offered health benefits to their employees, a driving force in [ObamaTax] compliance efforts is the avoidance of unanticipated tax liabilities and controlling administrative costs. As such, employers must take a holistic view ... to assess and valuate their risk for increased tax liabilities under the law."

Shorter version: bye bye group health plans.

Told ya so.

Oh! Those who wish to "read the whole thing" can download it here.

[Hat Tip: FoIB Jeff M]

Outliving Your Insurance

While it may seem counter intuitive, it is possible to outlive your life insurance policy. A lot of folks buy term plans with premiums that are level for 10, 20, even 30 years. But when that lock-in period expires, rates go through the roof. Often, we're much older and not necessarily in great health, making it more difficult - and expensive - to buy a new plan.

No problem, Henry, by that time my mortgage will be paid off, kids will be out on their own, and my 401k will be bursting with cash. I'll no longer need any life insurance.

Maybe, maybe not.

But as FoIB Jeff M tips us, you may be in for an unpleasant surprise:

"It is a fact that when the price guarantee ends on a level term insurance policy, the premiums skyrocket ... the only people who continue the policy beyond the price guarantee period are those who can't qualify for a new level [plan]."

Which isn't to say that term plans are bad: just that you need to know the pitfalls. And many (most?) plans are "convertable," meaning that you can trade them in for a permanent plan with premiums that never go up, even if your health has declined.

Nice to know.

Cavalcade of Risk #168: Come and get it!

Jacob Irwin presents this week's round-up of interesting risk-related posts, including his Top 3 picks.

The AMA, Medicare and PR

The "PR" in this case being Paul Ryan. We've been pretty rough on the AMA (whose membership, IB readers may recall, "represents only 17% of the doctors in the U.S."). But fair's fair, and one of that organization's committees has come out with a plan that looks just like...well, let's FoIB Avik Roy set the stage:

"[T]his past weekend, the AMA’s key policy committee, the Council on Medical Service, voted to endorse a Medicare reform plan that shares key traits with the ones put forth by Mitt Romney and Paul Ryan."

As Avik points out, the AMA-endorsed plan is heavy on choice and the defined-contribution model, just like Ryan's. And there's more, but you'll need to see Avik's post for that.

Tuesday Afternoon LinkFest

In no particular order:

■ As we've noted, the "Essential Benefits" facet of the ObamaTax continues to be up in the air. Those states that have gone "all in" on the train wreck have been sending out a flurry of info:

"More states have been posting essential health benefits (EHB) announcements on the Web ... [HHS Secretary Shecantbeserious' minions] are letting states express their EHB preferences."

Yeah, that'll end well.

■ Guardian Life has been looking at the extent to which employees actually value their employer-sponsored benefits. They've even come up with a unique "measure of perceived value" metric.

The study is available here.

■ From the Big Picture Department:

"Dr. John Butterly recently urged insurance regulators in New Hampshire to recognize the importance of reducing the entire cost of care for an entire patient and an entire population of patients."

Rather than addressing pieces of health care, he urges lawmakers and insurers to take the long view, including the difficult to ascertain costs of total care.

■ And finally, the Peach State thinks it can step on the Feds:

"Can Georgia control how quickly self-funded employer health plans pay doctors in the state?"

The US Department of Labor is the agency tasked with overseeing ERISA plans, which would seem like an insurmountable obstacle. The state law requires carriers to "pay claims in a timely manner" (whatever that means), but ERISA (self-funded) plans have typically been understood to be immune.

America's Health Insurance Plans (AHIP) has joined the fray, filing a suit in federal court seeking to block Georgia's insurance commish from enforcing the statute.

Sounds like fun.