Shecantbeserious Flails

Well, continues to flail is probably more accurate.

She and her minions still haven't found time to delineate specifics for the "Essential Health Benefits" portion of the ObamaTax. This is a set of core "benefits" that must be included in health insurance plans that want to participate in the Exchanges (yeah, we know) come 2014.

Badger State insurance commissioner Theodore Nickel "now has written to U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius to say that the state needs at least 60 days after HHS issues the final PPACA essential health benefits (EHB) regulations."

While she's dragging her feet on actually doing her job, Ms Shecantbeserious has found time to spread government largesse (ca$h) around to her buddies in the private sector, inking a "deal worth more than $3 million to promote [ObamaTax] “exchanges.” And yes, these are the same Exchanges that she can't be bothered to actually, you know, provide guidance for.

By the way, this is the second such deal for her friends at PR firm Weber Shandwick; back in 2010 they scored a cool $3.4 million contract ostensibly for promotion of Medicare fraud prevention and reporting.

Nice gig if you can get it, right Kathy?

Um, about that 3000% Premium Decrease (Redux)

As we've pointed out before (most recently here), the mythical decrease in health insurance premiums was always a fantasy, concocted by those who pushed to pass the ObamaTax (in order, of course, to find out what was in it). Now, FoIB Holly R tips us to the latest from my own neck o' the woods:

"Workers in Greater Cincinnati and Northern Kentucky will pay an average $4,775 out of their own pockets for health care in 2013, about $400 more than this year and nearly $2,000 more than 2007."

Ooops.

I can't help but notice that Mr Peale joins his journalistic brethren in continuing to conflate health care with health insurance. On the other hand, he at least tries to differentiate between them by noting that "payments include health care premiums through their employer, plus office co-pays and deductibles."

I give it a B-.

A star is born!

Our very own Kelley Beloff was part of an NPR roundtable last night, watching and commenting on the debate:

"Kelley Beloff, who works in the health care industry and leans right, says tax rates are impacting her vote, "I am totally middle class...and the big thing for me was hearing Mr. Romney talk about bringing down our taxes. My husband owns his own business, and we pay those individual taxes, and it is very difficult at times to make those tax payments."

Here's audio:

Musings: An Interview with Dr Rob

Dr Rob Lamberts, one of my very favorite med-bloggers, is making a major career change. He'll still be doctorin', of course, but in a new practice, based on a cutting-edge model of health care delivery. If you've never read any of his work, I heartily recommend that you do so.

After his residency at Indiana University in 1994, Dr Rob went into private practice with another physician (who subsequently went to Africa to do missions work). Their practice was initially owned by a hospital, but by 1996 they'd decided that it was better to leave and do "their own thing."

InsureBlog: What made you decide to chuck it all and re-boot?

Dr Lamberts: I had been frustrated as the other doctors in the practice grew more and more resistant to change. The more partners we had, the more inertia we gained. Since I am not a person to sit still when I think there are solutions to problems, I found it increasingly difficult to stay put because of others' personalities. This created conflict, which led to me looking at my options. Going solo in a practice that dealt with the insurance game and had the same limitations as the old practice was not a good solution for me, so when I found the Direct Primary Care (DPC) model it really appealed to me. In the end, my (now former) partners and I saw this as an irreparable split between us and the decision to split was mutual. They have worked it out so I don't have to draw a paycheck for up to 6 months, which gives me time to build my new practice right. They also gave me access to my patients to tell them about the new practice, which is a really generous thing on their part.

IB: You've mentioned that you may have patients that can't (or won't) follow you to your new practice, can you expand on that?

RL: The DPC model is one in which the patient pays the doctor directly for their care, usually in the form of a monthly "subscription," plus or minus a fee for visits. DPC usually limits the size of the patient pool as well, so I will only be able to take 1/3 of my total patient population even if all wanted to come (I had between 3 and 4 thousand patients in my old practice and will limit it to around 1000). Plus there is the fact that some patients are not going to be willing to pay what they see as an extra fee for care they already could get. Since nobody else in the area is doing this, the only way I can show that the value of the service will be worth the cost is to make it work. Some people will trust me in this, while others won't.

IB: I know a lot of practices are being gobbled up by hospitals eager to grow their ACO's [ed: Accountable Care Organizations]. Was this ever an option for you?

RL: Not really. If we were able to work out our differences in the old practice I would have been part of a primary care ACO that is being formed by a local IPA (group of independent primary care physicians who have allied together to do this). Primary care is quite independent in Augusta, and has recently done quite well in organizing and working together for their best interest (without risking collusion, despite what the hospitals may say). I could be part of an ACO in that setting if I wanted. In truth, however, I have grown less and less enamored with these models, as they are more driven by data and processes built around meeting care standards than they are built around good patient care.

We had been working on "Patient Centered Medical Home" in our practice, and I found that it was anything but patient-centered; it was data-centered, and took my attention away from the patients. Finally, I simply don't think the hospitals are the means to truly affect meaningful change in health care. They are the businesses that have been built on over-spending on health care, on unnecessary procedures, and on consumption of medical resources. The goal of most hospitals for my patients is 180 degrees from mine: their financial gain is built on people getting procedures, going to the ER, and being hospitalized, while mine is to help them avoid all of the above. [Continued below the fold]


IB: You mention at your site that you're adopting the "Direct Care Model." Can you explain how that works?

RL: DPC is basically a lower-cost concierge practice, but one that doesn't accept insurance at all. The payment goes directly from the patient to the doctor. My spin on it will be to use the freedom I have from removing the red tape of medicine (by dropping Medicare, Medicaid, and not accepting insurance) and build something that is radically patient-centered. Patients will pay a monthly fee (I am planning on it being around $50/month) and get access to my services.

Since I am not collecting copays (it makes no business sense to do so, as most of my income comes from the subscription and it makes billing far more complicated), I have no motivation to make people come in for care. I believe about 75% of my office visits in the old office could have been handled without forcing the patient to come in to be seen, so I am building my system so that it's easy for people to get information they need to handle their problems - either through direct contact with me (via phone or email) or resources I've made available to my subscribing patients. I also want to aggressively go after the patients who don't contact me, making sure their care is up to date and giving them a regular care plan as to the care they are due for, what's been done, and when upcoming care is due.

IB: Your new practice won't be accepting insurance. I'm curious how you'll determine pricing, what (if any) transparency do you envision?

RL: I am trying to find a price-point that will be attractive to patients and will pay me a good salary without working me too hard. I didn't like the typical "concierge" practice fees, as they excluded the majority of my patients. My intent is to say "This is what you will pay, and this is what you will get for what you pay," which is something very few doctors are even allowed to say. I am developing a list of deliverables that will come from paying the monthly fee, so I want to be absolutely transparent in this process.

IB: Kelley also wondered how are you going to ensure HIPAA regulations on patient confidentiality if you have notes posted on-line?

RL: I will use HIPAA secure software (leaning toward Avado now) which will give patients access without crossing the HIPAA line. How they handle that information (like accessing it on a public computer or printing it out) is not any different from what they did with lab results I mailed them. I don't see HIPAA as a big hurdle, in truth.

Thanks so much for your time and insights, Dr Rob, and our best wishes for your continued success.

Quote of the Day

"Fathom the hypocrisy of a government that requires every citizen to prove they are insured... but not everyone must prove they are a citizen."

Now add this, "Many of those who refuse, or are unable, to prove they are citizens will receive free insurance paid for by those who are forced to buy insurance because they are citizens."

[ed: incorrectly attributed to the great Ben Stein - but spot on nonetheless]

[Hat Tip: FoIB Debbie C]

Know Your EOB

EOB. Explanation of Benefits. A document that is mostly ignored and misunderstood by way too many people.

      

Your EOB is just as important as your bank statement or credit card bill. Yet far too many people never bother to read them.

Most health insurance EOB's are laid out well and relatively easy to decode. The billing codes and carrier explanations usually appear at the bottom of each page, or on the back if you get a paper EOB. Most plans also have online versions that can be viewed and printed.

Like your credit card statement, the EOB does you no good unless you check it each month.

Compare your Explanation of Benefits statement against your medical bills for each service. Doctor, lab, hospital, pharmacy, etc. Every medical provider that has your insurance information is required to file claims on your behalf with your insurance carrier. Par providers have time limits in which they must file or forfeit their right to collect from the carrier or patient.

A common health insurance complaint on consumer forums deals with "mysterious" medical bills showing up a year or more after service was rendered. Often the individual finds out about it when applying for credit and discovering a black mark on their report, or when they get a collection notice.

Really?

What happened to the bills from the medical provider? Do you ever open your mail?

Sometimes the patient bill is never generated by the provider's office due to an oversight. The shortfall is discovered during a routine audit.

This is where you need to get cozy with your EOB. If the provider was in network, and they never filed the claim with your health insurance carrier, you are probably not liable for the bill.

Regardless of whether the provider is par or non-par, or even if the provider filed the claim or not, YOU, the patient, are ultimately responsible for the bill. Failing to pay can impair your credit. Failure to pay could mean a denial of services in the future.

Check your EOB on a regular basis, especially if you frequently use medical services. The more you see a doctor, have lab work or diagnostic services, the more diligent you need to be in checking your EOB.

Retiree Plans Go Poof!

Retiree plans are dropping like flies. Johns Manville, American Airlines, 3M and Kodak are just a few corporations that have either discontinued retiree plans or have plans to do so.                    

Did you know there are sites on the internet that show CEO's how to maximize profits by terminating retiree plans?

Large employers continue to drop retiree health care plans – just 24 percent offered coverage to retirees under 65 and 16 percent to Medicare eligible retirees, compared to 29 percent and 21 percent the year before.

Chief Executive, "Control Health Care Costs in 2012"

What is causing this movement?

Much of the blame lies with Obamacare.

The increased direct costs that impact health insurance premiums plus additional oversight and compliance mandates are already causing many employers to consider dropping health insurance. Employees under age 65 will be able to purchase health insurance (possibly with a subsidy) through an exchange.

Retirees over the age of 65 can return to original Medicare and enjoy a GUARANTEED RIGHT to purchase a Medigap plan. 

When employers terminate retiree plans you may actually be better off than before. With original Medicare you can use any doctor, any hospital and never have to worry about networks, referrals or claim forms.

Many employers are subsidizing the cost of your Medigap coverage which means you may actually pay less than you did for the retiree plans and have more coverage.

Former employees of Johns Manville got this letter back in July that announced the cost cutting move cancelling retiree plans.

Johns Manville is moving from the current group health plan to providing a subsidy that you and your eligible spouse can use to enroll in any individual plans that supplement your original Medicare (Parts A and B) coverage, including Medicare Supplement, Medicare Advantage and Medicare Part D (prescription drug coverage), as well as for reimbursement of Medicare B premiums.

No longer will the cost of your insurance be deducted from your pension check or paid separately.

Rather, Johns Manville will provide a tax-free subsidy that will be available to you January first of each year through a ‘Health Reimbursement Arrangement’

Sounds like a workable plan to me. You have the freedom to choose any plan, including those that allow you to see any doctor. The cost of your health insurance plan will be subsidized through a "voucher" type system by way of an HRA.

As retiree plans become a thing of the past seniors age 65 and older will enjoy more flexibility.