Health Wonk Review Comin' Up

We'll be hosting next week's Health Wonk Review, and (as usual) the emphasis will be on "health policy, funding, insurance, managed care, infrastructure, IT, the uninsured, economics and trends."

You can submit your wonky post here, and be sure to include:

■ Your name
■ Your blog's name
■ Your post's link
■ A brief summary of the post

Submissions are due by next Wednesday (the 5th),  but early birds get better seats at the table (hmmm, bit of a mixed metaphor, that). And speaking of seats at the table, make sure to bring some apple sauce and sour cream (and maybe some peanut M&M's).

And matches. Definitely matches. Or a lighter.

Babies and Gramps: On the road to Death

Well at least they're consistent: The Much Vaunted National Health System© seems hell-bent on applying the same (dubious) health care standards on helpless infants as vulnerable seniors:

"Sick children are being discharged from [MVNHS©] hospitals to die at home or in hospices on controversial ‘death pathways'"

What they're talking about there is the Liverpool Pathway, about which we've written pretty extensively in recent weeks (for example: here and here). Typically, the LP had been used to dispose of decrease treatment for the elderly, since the MVNHS© had already been doing a bang-up job killing off post-birth-aborting children.

One can see their point, of course: much more efficient to combine the two programmes, and the Pathway has already proven quite helpful in reducing health care expenditures (well, health care, anyway) for seniors. We'd best be paying attention to this ourselves, since the ObamaTax is our version of that vaunted system.

Sweet dreams.

PHI and Speed Bumps

Yesterday, Bob posted on the increasingly intrusive role data and its management play in modern health care. But it goes beyond physicians typing in notes on their iPads:

"The small box inside Amanda Hubbard's chest beams all kinds of data about her faulty heart to the company that makes her defibrillator implant."

That data gets shot to her cardiologist, but is essentially inaccessible to Ms Hubbard.

Wait a minute, Henry, haven't we seen this show before?

Indeed we have:

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

All the pertinent data is collected and then sent back to the manufacturer, which then shares some of it with Hugo's doc."

So why the re-run?

Well:

"Medtronic [the device's maufacturer] says federal rules prohibit giving Ms. Hubbard's data to anyone but her doctor and hospital."

But it apparently doesn't prohibit Medtronic from seeking to make a buck off that data. The so-called "money quote," though, is this:

"[B]usiness agreements with doctors and hospitals restrict [Medtronic] to relaying information only to them."

This is reminiscent of the discounted rates insureds pay for in-network covered services, but which are excluded for those that fall outside the plan. That is, these agreements are quite lucrative for the providers (be they hospitals, device manufacturers or doctors), but not so much for the actual patient.

One argument will be that laypeople have no real use for the data because it's incomprehensible to them anyway; we already know from Mr Campos' experience that this isn't necessarily true.

A second argument would be that the law prohibits manufacturers from disclosing that data. Actually, my layperson's read is that since it falls outside the rubric of HIPAA (and/or the ObamaTax), manufacturer's aren't required to disclose it. Not quite the same thing.

So we'll ask again: Who (really) owns the data?

On Death Files, Competence and Confidence

As we noted last Spring, the Social Security Administration's Death Master File (DMF) "is itself rife with potential errors and misinformation." We reported this as part of our report on how life insurers are having an increasingly difficult time tracking down insureds and beneficiaries.

But there's another problem with that DMF, as well.

And this one's not so much about incorrect information as it is missing information.

One of my (very long term) clients lost her daughter 28 years ago, victim of a murder-suicide. Both her daughter and son-in-law have been gone almost 3 decades, but that didn't stop the government from reaching out to the long-dead perpetrator to remind him that he's now eligible for both Social Security and Medicare benefits.

But Henry, you may be asking, why are you even posting this?

Because it's just one more example (as if any were really needed) of how incompetent the Feds are at even the simplest of tasks, and these are the folks now in charge of our health care. In this case, it's simply a minor waste of postage, but what happens when it's your upcoming surgery?

Sleep well.

Doctor Click

Doctors are paid to treat patients, right? 

Back in the old days that was true, but not any more. Now they are paid to enter data.

Let me introduce myself, I’m a professional clicker.  I used to be a member of a highly respected and sought after profession; a doctor.  The modern world of government/insurer managed healthcare has turned me into an efficient clicker, busily documenting everything I do so that I can:

• Be reimbursed for my services

• Afford to pay my staff/landlord/utility/self

• Avoid being prosecuted for fraud by Medicare

• Avoid lawsuits

• Communicate with other docs

• Meet “quality” parameters set by Medicare/insurers

Kevin MD, "Click, click. How can I help you?"

The once noble profession of a physician where time was spent with patients discussing their issues is now replaced by a computer terminal. Face time is now screen time.

We did not create the system/game.  At every step of the way, we have been forced to play by Medicare’s and the insurers’ rules.  Not only have we been forced to play by their rules, we have also been forced to shoulder the expense of buying and learning to use the EMR (electronic medical record) that many of us did not want to use.

Second, the EMR made it easy to record what we never recorded in the past.  It’s hard to exam a person without examining his/her skin.  Acne and blemishes, skin color, texture and warmth are readily apparent.  In years past, only positive findings would have been recorded in my patient’s paper chart.  Now, click, click, click and it’s all recorded electronically.  In the old days, I knew what my notes meant.  Now, the rule is:  If it’s not recorded, you didn’t do it.

Think about that for a moment. You haven't really treated a patient until you have entered data in to a machine.

We are clicking because we are being forced to click.  In 2014, we will be financially penalized for not clicking.  Now, we may be penalized for being too good at clicking.  The government is on a witch hunt looking for fraudulent clickers.  Sometimes, you can’t win.

One more question needs to be answered.  Clicks are data points and are being collected every minute of the day by Medicare and the insurers.  What’s being done with all that data?  That question is the one keeping me awake at night.

Pleasant dreams . . .

MVNHS©: Cruel and Unusual

When bureauweenies run your "health care" system, this really shouldn't come as a surprise:

"Patients experience “coldness, resentment, indifference" and "even contempt” in some hospitals, the Health Secretary has claimed"

And why not? They're not paying the bills.

And so you get, well, government-run health care:

"[P]atients left to lie in their own excrement in Stafford Hospital, with members of the public taking soiled sheets home to wash ... The man with dementia who was supposed to be monitored every 15 minutes who managed to leave Pontypool Hospital and drown ... residents kicked punched, humiliated, dragged by their hair and forced through cold showers"

And the list goes on...

At the risk of stealing his thunder, Mike's been working on a post detailing a rather interesting and provocative theory of how and why this is the natural result of state-run health care systems (like, for example, the ObamaTax). Suffice it to say, there really is a perfectly good reason why this sort of behavior is becoming "the new normal."

And the fact that the Brits' version of Mme Shecantbeserious is just now lashing out only serves to underscore how putting government agencies between ourselves and health care providers never ends well.

LTCi Gets More Expensive

Kinda wondered when the carriers would get around to this:

"Until now, insurers have charged the same premiums regardless of gender for [Long Term Care insurance] policies ... beginning early next year, Genworth Financial, the country's largest long-term-care insurer, plans to start charging women applying for coverage as much as 40% more than men."

This actually makes sense: women tend to live longer than men, so have an increased chance of needing some kind of assistance. As a result, two thirds of LTCi claims dollars go to the fairer sex. Add in carriers' measly investment income in these low-interest rate times, and there's a recipe for some major problems.

And don't be surprised to see underwriting tighten up, as well, as carriers are starting to better understand long-term trends.

And there's this: just because Genworth's going first doesn't mean that the other carriers won't follow their lead, so look for plan prices to begin jumping pretty soon.

Ouch.

Cracks in the MVNHS©?

Hmm, this sounds familiar:

"The [MVNHS©] can’t go on like this. Patients today – baby boomers, especially – bother the doctor with minor complaints ... and have unrealistic expectations of what the health service can provide. The system is at breaking point ... We are going to have to start paying for some medical services at the point of delivery."

Heh.

So the Much Vaunted National Health System© has been no more successful at reining in costs with "free" health care than our own "dysfunctional" system?

Who'da thunk it?

Oh, yeah.

This diagnosis, by the way, comes from physician (and Tory MP) Phillip Lee, who adds that the system "probably can limp on for the rest of this decade ... but the reality is the pressures coming from the baby boomer generation and their expectations of health care, their perceptions of pain and suffering is profoundly different [than] their stoic parents who survived the war.”

In other words: suck it up, buttercup.

Or it's hit the Pathway for you.

Cavalcade of Risk #171: Up and running

Emily Holbrook hosts this week's episode featuring the best of risk-related posts from around the 'sphere. It's short, sweet and packs a punch (and a mighty hammer, too).

Wally World Meets Snoopy

Walmart and MetLife just announced they’ve launched a pilot life insurance program at 200 stores in Georgia and South Carolina. Customers can choose between two coverage options — $10,000 or $25,000 — with prices varying by age. An 18- to 44-year-old can purchase a one-year $10,000 policy for $69. Older people pay more, with a one-year $25,000 policy for a 60- to 65-year-old priced at $429.

Consumers buy the insurance by picking up a prepaid card and then calling MetLife’s toll-free number to answer health questions posed by a life agent. If the customer qualifies for coverage, the policy is activated. If coverage is denied, the card can be returned to Walmart for a full refund.

WalMart Moved Your Cheese

Yeah, about that promise...

You know the one:

"If you like your health insurance you can keep your health insurance."

That sound you hear? It's that promise going under the proverbial bus.

From Medical Mutual of Ohio (email):

"As part of the renewal process for our individual health plans ... we will introduce several key changes starting with January 2013 renewals.

... the Internal Revenue Service (IRS) changed the 2013 key amounts for health savings accounts (HSAs) and HSA-qualified high-deductible health plans.

Due to the revised guidelines, we can no longer offer Wellness HSA 1200 plans to our SuperMed One and Ohio Farm Bureau members. As a result, we will transfer all members enrolled in these plans at their renewal.

SuperMed One members will move to the Wellness HSA 1500 and Ohio Farm Bureau members will move to the Wellness HSA 1750. These members will see an increase in their deductible"

Ch-ch-changes, indeed.

Off the Beaten Path(way)

As we noted late last month, MVNHS© "trusts" (hospitals) that participate in the British Death Panel Liverpool Care Pathway have been handsomely rewarded for their efforts. This makes sense: by scrimping on care they save the system cold hard cash, thereby earning their (not so) little finder's fees.

But all that may be coming to an end:

"Ministers ... ordered an independent inquiry into why hospitals have been paid to hit targets for numbers of patients dying on the Liverpool Care Pathway."

I'm sure this will be welcome news for those currently on the path; for those whose lives bought Angus steak dinners for the bureauweenies, not so much.

I did find this little tidbit darkly humorous:

"Mr Lamb said the inquiry would ‘consider the value of locally set incentives, and whether they are leading to bad decisions or practice’"

Well, that really depends on whether one believes killing off patients is a bug or a feature, doesn't it?

ObamaTax Job Killer

As we've previously noted (most recently here), the ObamaTax is quite the efficient job killer.

Orlando Health (FL) is a large hospital system employing some 16,000 folks.

Strike that.

Orlando Health (FL) is a large hospital system which used to employ 16,000 folks, but which has just downsized 400 of them in anticipation of changes being wrought by the ObamaTax.

Meanwhile, the Community College of Allegheny County (PA) is drastically reducing the hours of 400 employees of its own. These adjunct professors will be re-classified as part-time to avoid the ObamaTax Employer Mandate. But of course they'll be able to find quality, affordable coverage of their own through the Exchange.

Eventually.

Right?

And speaking of killing the goose that lays the golden eggs jobs, here's an ObamaTax "benefit" that's been flying under the radar:

"Section 4205, the menu labeling provision .... meant to “aid consumers in selecting more healthful diets” ... the regulation will likely have job-killing effects and result in little, if any, significant reductions in obesity rates and/or improved health."

The problem is that, as benign as the idea might appear, it is just one more unfunded (by gummint) mandate that will drive up the cost of doing (food) business, with no discernible positive effects, but with the very real consequence that employers will have to pay for implementation at the cost of their employees' jobs.

Ooopsies.

A Belated Thank You

I inadvertently let Thanksgiving come and go without acknowledging the invaluable contributions made by my fantastic co-bloggers.

I'd like to remedy that:

Thank you Bob, Mike, Nate, Kelley and Bill for all of your great posts, insightful advice and unstinting help here at IB.

There's no better team in the blogosphere.

"Free" keeps getting more expensive

Dr Peter Weiss, Director and Founder of The Rodeo Drive Women's Health Center, is finally catching on to at least one ObamaTax gotcha, the "free" annual exam. As Bob noted last summer, "if you don't follow the rules, your free annual exam could cost you $500 - $1000 or more."

Fast forward a few months, and Dr Weiss reports some changes reflecting this reality at his practice:

"I have now posted a notice in my office and each exam room stating exactly what Obamacare will cover for those yearly visits. Remember Obama promised this as a free exam — no co-pay, no deductible, no charge. That’s fine and dandy if you are healthy and have no complaints."

Aye, thar's the rub: as long as you're fit-as-a-fiddle in the first place (and/or if you had previously treated and now stable conditions) then you're likely to get out of the examining room with wallet intact. But woe to the patient who also has new issues:

"[Y]ou will not be covered if you want to discuss any new ailment or unstable condition. I cannot bait and switch to another code — that’s illegal."

In other words, if you're in for your routine exam, make sure not to ask the doctor about your stiff neck or new-found acid reflux. You'll need another appointment for that, one in which your deductible or co-pay will apply.

But hey, it's free, right?

BONUS: Dr Weiss also takes his scalpel to the canard of "the rich doctor" (gee, where have we heard that term before?):

"[D]octors are not rich and, like most of you, actually work terribly hard for a living. Second, Obamacare is the law — and as I said earlier, we are audited all the time now."

And this is only going to get worse: as we've noted, there's already a shortage of providers, and Dr Weiss thinks we're seeing just the beginning of of that trend:

"By 2014, less than 25% of physicians will be in private medicine. Obama was right in stating you can keep your doctor if you want to — the problem is he or she will rarely be available."

Three cheers for the ObamaTax, no?

ObamaTax Rule Dump: More Questions Than Answers

As Bob noted the other day, we're still awaiting final rules on full implementation of the ObamaTax. But that's about to change.

Today, HHS Secretary Shecantbeserious is set to "pump three major [ObamaTax] regulation proposals into the Federal Register." These include new rate review rules (say that 3 times fast!), the new group wellness program rules, and new provider accreditation rules.

Of course, the phrase "clear as mud" comes to mind, but I'm sure that there'll be no problem implementing all of these rules, and that providers and insurers will be delighted to comply with them. After all, it's only taken almost 4 years to develop them.

Meanwhile, some parts of the ObamaTax have already been rolled out, and their effects are starting to take their own toll. For example, the 2.3% medical device tax:

"This damaging tax will force job cuts and investments in tomorrow's treatments and cures ... Continued medical innovation is key to driving public health gains by reducing costs associated with chronic diseases like diabetes and obesity ... Simply put healthier lives mean healthy economies."

That last bit is a sketchy (I've never seen that particular claim before, nor evidence of its veracity) but the rest is spot on. Throwing up additional barriers (ie taxes) like this discourages new tech, while making the delivery of health care ever more expensive.

But then again again, that's apparently where the IPAB Death Panels come in.

How pointless will CER be...

...and how long till we realize it was nothing but a slush fund for Obama like his green jobs money?


"The routine use of mammograms has led to more than 1 million women being unnecessarily treated for breast cancer over the past three decades, according to the latest scientific report to cast skepticism on the effectiveness of the test."

"Even before those findings, in November 2009, a key federal panel revised its guidelines on mammograms to say that women should begin regular screenings at age 50 rather than age 40, and then get the exam every other year rather than annually."

"In 2010, lawmakers tweaked a mandate in the health-care law requiring insurers to cover preventive services recommended by the task force free of charge. The law specifies that when it comes to mammograms, insurers must follow the task force’s old guidelines"

Why spend the money if we are just going to ignore the results? 

Do premiums matter under PPACA?

As a small claims payor I am always keeping my eyes open for experienced claim processors by searching resume boards. The last few months I have seen a large number of adjusters that used to work for Anthem. Normally you don't see adjusters leaving the large carriers as they pay great and have better benefits and retirement opportunities. Seeing a couple let alone a dozen is rare. In speaking with a few of them I was told they outsourced their claims processing to the Philippines and India. This got me wondering what this foretells of the future.

If you're a carrier and you're locked into 15% of revenue, do you spend that money on claims adjusters to control your claims cost, and thus reduce your revenue...

...or do you auto-adjudicate as many claims as you can, 70-80%+, then outsource the remaining claims to some low cost foreign country?  They won't do as good of a job (meaning they will pay more in claims then they should) but that actually increases their revenue, a perverse reward for a job poorly done.

This has been the Medicare model for decades and resulted in the most inefficient and fraud ridden program in the country. But if no one is directly paying the bill who cares? Medicare beneficiaries pay a minute fraction of the actual cost of their benefits so they don't care if 10%+ is lost to fraud. If the majority of the exchange members are going to be subsidized they won't mind either. The only people that would care are workers actually paying federal taxes, a minority when it comes to voting.

From the anecdotal evidence I have seen so far, it appears private insurance is adopting the worst qualities of Medicare already, before the exchanges even start.

For claim processors, 60% of expenses going to salaries is normal; if you drastically reduce that the business goes from low margin commodity to very profitable very quickly.

This Sceptered Isle - Part CCXXIV

"A new system of “virtual clinics” is being planned in which GPs connect with patients via iPads and Skype, an idea that NHS bosses are importing from India.  The reforms would save £2.9billion “almost immediately” and improve the lives of most patients, for example by avoiding the need to find child care during appointments, Health Minister Dr Dan Poulter said last week."

Notice the best NHS can say about this "reform" is that this will improve Brits' lives by "avoiding the need to find child care during appointments"?  Really? That's it??

But don't forget - NHS will save £2.9billion ($4.65 billion)  “almost immediately”.  We must assume those savings will also improve the lives of most patients almost immediately even though the article does not say how. 

Anyhow my guess is, if you're not British, and not a patient, you won't much care.  This kind of thing could never happen here. Government doesn't have that much control over the U.S. medical care system.  Right?

An Exchange of Ideas

Almost 3 years after Obamacare was signed in to law and there is as much, if not more uncertainty than before. All the campaign promises, "You can keep your plan if you want", "Your premiums will drop by $2500 (or 3000%)", and so forth have been proven to be lacking in honesty and integrity.

We are a little more than a year away from the deadline for FULL implementation (1/1/2014) and still the states have no real clue what is expected of them with regard to the exchange.

This should come as no surprise since Washington has arbitrarily usurped the legal authority of the states to set policy provisions, approve contract language, establish reserve requirements, minimum loss ratio standards, as well as setting and reviewing rates.

Confusion abounds.

States, carriers and consumers alike have been left in the dark when it comes to rules, guidelines and interpretation. The law, as written, says one thing, but then the HHS Dept. decides it means something else.

The law applies to everyone equally . . . unless of course you were granted a waiver or exception.

HHS has decided the law even trumps your religious rights and beliefs when it comes to items such as birth control or abortion.

So why should the rules concerning exchanges be any different?

In an open letter to HHS, Gov. Terry Branstad (Iowa) raised several (still unresolved issues and questions) regarding Obamacare and the exchange.

1)     Please provide a complete list of regulations that will have to be reviewed, revised and re-opened for public comment prior to implementation as a result of the Supreme Court ruling (e.g., the Medicaid eligibility regulations, exchange regulations related to interface with Medicaid). What is the schedule for re-issuing these regulations? 

         2)    When will final rules be issued on essential health benefits, actuarial value and rating areas? 

3)     The federal government has already extended deadlines for applying for Level 1 and Level 2 Exchange Establishment funding into 2014. Can we expect extensions of the deadlines for other areas of implementation given the uncertainty caused by the Supreme Court ruling and the linkage between Medicaid expansion and exchange eligibility and enrollment functions? In addition, will the deadlines change for states implementing a partnership exchange? Will the deadlines be extended for states implementing a federal exchange? Can you confirm that states will be able to switch from a federal model to a partnership or state model until 2019 and that funding will be available to enable that transition? 

4)     When will the details of the federal partnership options be available? These cannot be considered as an option without details including cost estimates and how state and federal systems are expected to link. How will the long term funding of the federally-facilitated healthcare exchanges be sustained? 

5)     States considering a state-based exchange need to know whether there will be a charge to use the federal data hub, advance premium tax credit/cost-sharing reduction service, risk adjustment and transitional reinsurance programs. Will there be a charge? And, if so, how much will it be? 

All good questions, along with 45 more on this site.

We were also promised that "Gitmo" would be closed by this president. Almost 4 years later and the prison is still open.

Makes you wonder when, or if, Obamacare in its' final form, will happen.

Cavalcade of Risk #171: Call for submissions

Emily Holbrook next week's Cavalcade of Risk - Entries are due by Monday (the 26th).

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!

Remembering the First Thanksgiving

One of the earliest and arguably most historically significant North American colonies was Plymouth Plantation, founded in 1620 in what is now known as Plymouth, Massachusetts.

The original Plymouth Plantation had written into its charter a system of communal property and labor.

illiam Bradford recorded in his Of Plymouth Plantation, that a people who had formerly been known for their virtue and hard work became lazy and unproductive. Resources were squandered, vegetables were allowed to rot on the ground and mass starvation was the result. And where there is starvation, there is plague.

Plague. Lest we forget: there was, and remains to this Thanksgiving Day, an unbreakable connection between economic productivity and public health. The Plymouth Colonists' very survival was threatened (and they had neither NHS nor ObamaCare).

After 2 1/2 years, the leaders of the Plymouth colony decided to abandon their socialist charter and create a different system - one which honored private property.

Under their new system, the colony not only survived but thrived, and the abundance which resulted was celebrated at the iconic First Thanksgiving feast.

More here.

May everyone enjoy a peaceful Thanksgiving Day with our families and loved ones - and may we also not forget where the bounty of our great country actually comes from.

Health Insurance Rate Increase

No one likes a health insurance rate increase. Too bad. It is coming whether you like it or not.

Courtesy of Obamacare . . .

Beginning in January, 2014, if you have an individual or family health insurance policy issued (or modified) after March 23, 2010 your policy MUST conform to the new federal guidelines. This means adding at least 10 new benefits you may not have on your current plan and may not want.

Beginning in 2014, all non-grandfathered health insurance coverage in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and

Basic Health Programs (if applicable) will be required to cover essential health benefits (EHB), which include items and services in 10 statutory benefit categories, such as hospitalization, prescription drugs, and maternity and newborn care, and are equal in scope to a typical employer health plan.

HHS release regarding rules for PPACA

What are Essential Health Benefits?

Plan provisions the government says your health insurance policy must have, or else you are not in compliance and must pay a penalty.

Here is a link to the HHS bulletin defining your mandated EHB's.

Here is the abridged summary.

physician and specialist office visits, inpatient and outpatient surgery, hospitalization, organ transplants, emergency services, maternity care, inpatient and outpatient mental health and substance use disorder services, generic and brand prescription drugs, physical, occupational and speech therapy, durable medical equipment, prosthetics and orthotics, laboratory and imaging services, preventive care and nutritional counseling services for patients with diabetes, and well child and pediatric services such as immunizations.

You may be thinking, this doesn't sound too bad.

Consider this.

ALL health insurance policies issued or modified after 3/23/2010 must include benefits and pricing for maternity and pediatric services. All policies.

It doesn't matter if you are young, old, male, infertile. Your policy MUST have those benefits and you will pay for them whether you like it or not.

And how about those mental health services, including substance abuse?

Psychiatric services can be very expensive and many existing health insurance policies either do not cover treatment or limit you to maybe 20 visits per year.

No more.

Starting in 2014 ALL policies must cover mental health services as any other illness. Unlimited doctor visits. Unlimited inpatient treatment. All very expensive.

How much will all this cost?

Glad you asked.

In addition to offering EHB, these health plans will meet specific actuarial values (AVs): 60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and

90 percent for a platinum plan. These AVs, called “metal levels,” will assist consumers in comparing and selecting health plans by allowing a potential enrollee to compare the relative payment generosity of available plans. Taken together, EHB and AV will significantly increase consumers’ ability to compare and make an informed choice about health plans.

Yes, the federal government is going to make it EASY for you to pick a plan . . . and they will make it affordable according to actuarial values for metal plans.

It will be just like going to a fast food restaurant. Give me a bronze plan and a gold plan to go.

Now that you know all this, go enjoy your Thanksgiving.

Obamacare Latest Release

Time marches forward, and HHS, CMS, IRS, DOL, EBSA and others are weighing in on the future of health insurance coverage.

States and insurers have been waiting for the proposed rules. One proposed rule looks at how insurers can vary premiums based on age, tobacco use, family size and geography. A second outlines proposed rules for essential health benefits. A third proposed rule would govern employer-based wellness programs.

Kaiser Health News, "Proposed rules on essential health benefits"

They also put the "un" in affordable . . .

every American, for the first time, will have access to affordable health insurance coverage notwithstanding any health problems they may have. In addition, also for the first time throughout the nation, health insurance issuers will be prevented from charging individuals and small employers higher premiums due to enrollees’ health status or gender.

HHS

Even HHS and CMS admit these provisions will inflate costs more than any other provisions.

It also grants extensive oversight for premium adjustments. This area of regulation has, prior to Obamacare, been the sole responsibility of the states.

Obamacare runs roughshod over those laws and in essence makes health insurance a nationally regulated commodity.

require that health insurance issuers submit data on proposed rate increases in a form and manner to be determined by CMS, and amend the requirements for a state to have an Effective Rate Review Program.

The law requires that, beginning in 2014, the Secretary of the Department ofHealth and Human Services (the Secretary), in conjunction with states, monitor premiumincreases of health insurance coverage offered through an Exchange and outside of an Exchange. The Secretary will monitor these increases to identify patterns that could signal market disruption and assist in oversight of the new market-wide rating reforms created by the Affordable Care Act, which are effective on January 1, 2014.

In other words, if  HHS and CMS feel the states are not doing their job in holding down premiums the federal government will assume that role.

Keep in mind the federal government also has oversight of all aspects of Medicare. They determine plan design, premiums and provider payment schedules.

Given that Medicare is underfunded and has no real cash in the Trust Fund, how well do you think they will run Obamacare?

Winning Carrier Trick

Bob's written before about P.A.R.E. claims (Pathology, Anesthesiology, Radiology, Emergency), wherein certain providers choose not to participate in networks, and thus are free to charge pretty much what the market will bear. While there's not much one can do about that, one can at least reasonably expect such providers to follow the rules that are in place.

Like not double-billing for the same procedure:

"Blue Cross and Blue Shield of North Carolina ... argued that radiology practices were charging double for services provided only once and wanted the opportunity to cut reimbursements. It estimated that some $16 million was improperly charged annually because of this billing method."

That's not exactly pocket change.

As one might expect, the radiologists cried foul, arguing that this was tantamount to a contract re-negotiation without, you know, negotiation. BX countered that they were simply looking to "protect consumers and our customers from unreasonable charges."

In the end, the Tar Heel State's Department of Insurance sided with the BX folks; the losers doc's retain the right to appeal the decision in court.

[Hat Tip: FoIB Jeff M]

Bed Tax

"'Round and 'round we go and where we stop nobody knows".  A familiar phrase to some, but very appropriate when it comes to Georgia hospitals.

The state’s “bed tax” — a fee that Georgia hospitals pay to help prop up the state’s Medicaid program. Hospitals pay the bed tax to the state, and the state sends the money back to them according to the level of Medicaid care they provide. The scheme has meant millions in revenue for Children’s and millions in losses for Piedmont; that’s because 55 percent of patients at Children’s Healthcare are on Medicaid; at Piedmont Hospital in Buckhead, the total is less than 3 percent.

AJC, "Bed tax hospital windfall or loser"

It depends on whose ox is being gored.

Hospitals that depend on Medicaid payments become "winners" while hospitals that treat patients that pay their own bills (with or without private insurance) become losers.

Expect this redistribution of wealth to become more protracted in the post 2014 Obamacare world.

In metro Atlanta, Grady Memorial Hospital and DeKalb Medical Center also see a windfall from the bed tax, but the fee acts as a financial drain on St. Joseph’s, Emory University Hospital and Northside Hospital as well as Piedmont.

Grady is the local charity hospital supported by taxes and Medicaid. St. Joe, Emory, Northside and Piedmont have mostly private pay patients.

 Hospitals pay a “provider fee” of 1.45 percent of net patient revenue. (Trauma centers pay 1.40 percent.) The state uses the money to pump up what it pays hospitals to treat Medicaid patients by 11.88 percent. Because the Medicaid program is jointly paid for by the states and the federal government, Georgia can use the money collected from the hospitals to draw down federal matching funds.

The fee is designed to help level the financial playing field among hospitals, since Medicaid pays less than what it costs to treat patients covered by the plan.

Yes, Medicaid pays less than any other form of insurance. Makes you wonder how this will play out in 2014 and later when the Medicaid rolls are expected to expand by 15 to 20 million.

This Obamacare thing is not going to be pretty.

Die, Baby, Die (MVNHS© Edition)!

Turns out, it's not just our Neighbors to the North whose health care "system" has no real use for the weakest among us. Across the pond, the Brits' Much Vaunted National Health System© has its eye on the prize, as well:

"A mother has described how her baby was left to die 'like an abandoned animal' after hospital doctors repeatedly ignored her desperate pleas for help."

Hayley Fullerton, barely a year old, had survived a major heart procedure, but experienced complications that left her struggling to breathe. Her mother tried, desperately but unsuccessfully, to get those compassionate government health care "providers" to even look at the little girl.

Of course, they couldn't be bothered.

Nearly 3 years later, an official inquest concluded that "there had been 'serious failings' in Hayley's care."

Um, dunh?

Oh, but there's a bright side:

"Birmingham Children's Hospital admitted full liability for her 'avoidable' death."

See, everything's doddle!

[Hat Tip: Power Line]

MedTourism close to home

One of the issues we've had with the Not So Vaunted Health System© is that health care is becoming more scarce. As providers scramble for a way to stay in business, the cash-only model of health care delivery seems to be growing in popularity.

On the other side of the ledger, employers looking for ways to rein in health care costs are thinking outside the box, as well:

"This year, grocery giant Kroger Co. has flown nearly two dozen workers to Hoag Orthopedic Institute in Irvine and several other hospitals across the U.S. for hip, knee or spinal-fusion surgeries in an effort to save money and improve care."

As Bob reported last week, Wal-Mart is offering its employees free heart and spine surgery at a half dozen health centers of its own.

A major challenge is, as we've so long lamented, the lack of consistency and transparency in the cost of health care. Compounding the problem is the fact that there are separate fees for each service, so that a patient receives a bill from the hospital, the surgeon, the anesthetist, and so on. So-called "global billing" hasn't really happened, so employers are taking a cue from the cable and phone companies, putting together "bundles" that can help hold costs down and make price negotiations more meaningful.

As Rand Corporation's senior policy analyst Susan Ridegly puts it:

"We want to stop paying by the widget in healthcare."

Well said.

Ohio Draws a Line [UPDATED]

[Although we rarely do this, I am changing the published headline of this post to more accurately reflect what's actually going on. HGS]

This just in:

"Ohio will let the federal government run its health care exchange, a key portion of health care reform, Gov. John Kasich said today."

Oh, well, guess that means we avoid a nasty state constitutional crisis.

And this is priceless:

"Benefits of a federal exchange start with cost ... annual operating costs of a state exchange would range from $19 million to $34 million, excluding technology. Fees from providers and insurers would pay most of those costs." [emphasis added]

Yeah, be sure to let us know how that works out.

Not to mention: Buckeyes now get the privilege of susbsidizing the folks in states that set up their own Exchanges, forcing up our costs while driving down theirs (at least for a while).

Yippee!

[Hat Tip: FoIB Holly R]

UPDATE: Unlike Ohio's Gov Kasich, Pelican State Gov Bobby Jindal was a bit more forceful in rejecting a state-built ObamaExchange. Co-blogger Mike tips us to the Governor's official rejection:

"The full extent of damage the PPACA causes to small businesses, the nation’s economy, and the American health care system will only be revealed with time. The State of Louisiana has no interest in being a party to this failure by implementing a state based exchange."

That's gonna leave a mark.

UPDATE THE 2ND: And now add Texas to the list:

"Texas Gov. Rick Perry officially notified the federal government on Thursday that the state will not set up an exchange to help people buy health insurance."

I'm wondering if perhaps thinking that my title for this post was inappropriate.

Hmmm....

UPDATE THE 3RD: Thanks to the folks at RedState, here's the latest tally of states which have told Shecantbeserious to take a flying leap off the nearest ObamaExchange:
Kansas

South Carolina

Florida

Wyoming

Nebraska

South Dakota

Louisiana

Texas

Wisconsin

Arkansas

Alabama

Maine

Indiana

Iowa

Georgia

Ohio

Obamacare Cliff Hanger

Today is the day. States must decide today if they will set up a state run Obamacare health insurance exchange. If they refuse, the federal government will establish and run the exchange for them.

Seems a no brainer to me.

States have limited resources. States must adhere to a balanced budget.

Contrast with the federal government with unlimited access to money.

The federal government has admitted that it can't pay for this health care 'marketplace', which would cost between $10 to $100 million per year in each state. Hence the necessity for each state to set up its own exchange, shouldering some of the costs.

The problem with that notion is that nowhere in the 2,700 page behemoth known as the Affordable Care Act, is it written that the states will be required to do so; the assumption being that the states would simply go along with the federal governments wishes.

Freedomworks, "State run exchanges, last hope against Obamacare"

Rather pompous, don't you think?

We (federal government) don't have the money to run the health insurance exchange so you (states) do it for us? 

Because of this (lack of state run exchanges), the government cannot legally enforce the employer mandate "tax" on employers in a state that has not set up an exchange.  Without the employer mandate, and without the exchanges to manage the insurance subsidies, ObamaCare falls apart.

That's a mouthful.

It also brings up this point.

With regard to the health insurance exchange, states have the power to say "We didn't build that".

Oklahoma, Okay?

A month ago, Bob posted on a "unique practice at the Surgery Center of Oklahoma" which accepts only cold, hard cash on the barrel head.

No insurance, no Medicare or Medicaid, no third party payors of any kind.

So, how's that working out for the folks who run the joint?

From the horse's mouth:



[Hat Tip: Hot Air]

Consequences and Eddies

The fallout from the recently affirmed Not So Vaunted Health System© continues to build. And it's not just pizza, but a host of seemingly unrelated institutions.

FoIB Jeff M tips us to the recent announcement by Wake Forest Baptist Medical Center, which has recently axed almost 1,000 employees as a result of "the challenges of health-care reform, federal budget deficits and a decline in research funding from The National Institutes of Health and private industry.”

But it's not just the Baptists. At the other end of the spectrum, "the Roman Catholic church will not comply with the Obama administration requirement that most employers provide health insurance covering birth control." This is in response to the convenience items birth control mandate handed down by HHS Secretary Shecantbeserious.

And the hits just keep on comin': Palm Beach, Florida restaurateur John Metz has come up with a novel way to unbundle the extra costs of the NSVHS©. He's planning to "charge his customers a five-percent surcharge and decrease his employees’ hours to offset the costs of Obamacare on his businesses."

That's really a two-fer: by specifically noting the extra charge, customers get a real-world intro to the extra costs the train-wreck imposes on business. And servers get to see the effects of these costs on their own lives, both in terms of fewer hours (and lower net pay) and, presumably, lower tips (and thus lower net pay) as customers decide how much that service is worth versus the surcharge.

Talk about a Grand Slam.

Merp, Merp!

Hard to believe, but we really haven't covered Medical Expense Reimbursement Plans (MERPs) much here at IB. Back in August, Nate alluded to them when discussing small group plans and Health Reimbursement Arrangements (HRAs). MERPs allow an employer to help employees pay their health insurance premiums (among other things). Hamilton County (OH) is trying one out in an effort to manage its out-of-control health insurance costs by encouraging its employees to bail on the County plan in favor of a spouse's (or another job's).

It's kind of a neat deal, actually:

"Hamilton County, which employs about 4,000, is doing everything it can to prevent layoffs ... The MERP Hamilton County is implementing is a bit different from a traditional MERP ... The plan reimburses medical expenses incurred under “alternate coverage”

To get the full benefit of the plan, an employee has to waive off the County insurance plan in favor of the aforementioned spouse's or other employer-based health insurance plan. Interestingly, that plan cannot be a Health Savings Account. No can do? Fine, then stay on the County plan, but count on getting dinged more on your premiums.

And there's this: in addition to reimbursing an alternate plan's premiums, the new MERP will also help towards that plan's out of pocket expenses (deductibles, co-pays and the like). Even with all that, the county is looking to save upwards of $3 million next year.

Getting folks off group plans isn't new - we've seen this trend for a while. But it's generally been a "if you can go on your spouse's plan, you must go on it" type of deal. This "carrot" instead of "stick" approach may be the next big thing.

Thanks, Bob, for the tip!