One of the challenges I face most often these days, in our pre-2014, marketplace is helping give the small business owner some peace of mind when facing finding insurance when they have a family member with a pre-existing medical condition. For the purposes of this commentary, let’s define a pre-existing condition as something causing a decline in the Individual/Family market.

I often get referred to hopeless people faced with “nobody will insure me”. Well, as a skilled broker, committed to helping insure and provide peace of mind to as many clients as possible, most cases are not hopeless. Many times, the husband and wife business can get Small Group Health on a Guaranteed Issue basis. What does that mean? They cannot decline you for medical issues, or namely pre-existing conditions. All we have to do is prove we are a viable business here in California per the guidelines of AB 1672, which is the statute that defines small businesses in California.

So, when faced with a client who has been declined for health Insurance in the IFP market, I first ask if he or she is married. As long as they are married, we can get them GI Group Insurance in California. Period. If they have a Corporation, we need a current Statement of Information listing both husband and wife as Officers (not Directors) of the company. If they are not Incorporated, we can place them with two carriers who have liberal interpretations of AB1672. All they need to do is get a Business License that lists both the husband and wife as owners of the business entity of choice, and we can get them coverage.

One client was recently referred to me with a daughter, a little less than two years old, experiencing some medical issues that she would grow out of, but declinable conditions in the Individual/Family Plan Market at this time. They came to me with three weeks of Cobra to go…almost in a panic. They followed my instructions to the “t”, and promptly got the coverage they wanted for less than they were paying on Cobra and most importantly eliminated that panic from our first call.

Another client had he and his son on an IFP plan and his wife on a state HIPPA plan. We were able to consolidate all of them onto one plan, significantly improve the benefits to all, and save him some money each month.

In another case, I was working with a woman and her husband in the IFP market, and one of them was declined. She was feeling hopeless…I was able to get the carrier to re-visit their situation, provide a letter of explanation, and they were ultimately offered coverage by that carrier, saving them significant dollars in their monthly budget, while significantly improving benefits. Working with an experienced broker, with a reputation with the carrier can often pay dividends even though it costs you nothing!

Bottom line, I keep saying that here at the David Lindsey Agency, we are Insurance Specialists charged with creating peace of mind for our clients in this challenging and changing Health benefits climate we have now. We work hard to help our clients sleep at night so we can too!

1 in 4 Patients Undergoes Revolving-Door Hospitalizations

THURSDAY, June 3 (HealthDay News) -- About one-quarter of all U.S. hospital patients are readmitted over a two-year period for the same conditions that led to their original hospitalization, a new study finds.

These revolving-door figures came from the federal Agency for Healthcare Research and Quality, which analyzed 2006-07 data on 15 million patients in 12 states. Among its findings:

More than one-third of patients with hardening of the arteries (atherosclerosis) were readmitted at least once to the hospital, along with 30 percent of patients with uncomplicated diabetes, 28 percent with high blood pressure, and 21 percent with asthma.
Among Medicare patients, 42 percent had multiple hospital admissions and 38 percent had multiple emergency department visits.
Among Medicaid patients, 23 percent experienced multiple hospital admissions and 50 percent had multiple emergency department visits.

Rates of hospital readmissions and multiple emergency department visits were 22 percent and 38 percent, respectively, for uninsured patients and 19 percent and 29 percent, respectively, for privately insured patients.

Although some patients do need to be readmitted, better outpatient care could prevent unnecessary repeat hospital admissions, which in turn can push up health care costs, according to the AHRQ.

The data in the study came from Arizona, California, Florida, Hawaii, Massachusetts, Missouri, Nebraska, New Hampshire, New York, South Carolina, Tennessee, and Utah.

More information

The AHRQ has more about health care quality.

-- Robert Preidt

SOURCE: U.S. Agency for Healthcare Research and Quality, May 27, 2010, news release.

 

Sally C. Pipes: The Massachusetts health care mess is coming soon to the rest of America
By: Sally C. Pipes
OpEd Contributor
June 11, 2010
 
Devotees of big government, like Archimedes, believe that if they have a long lever and a place to stand, they can move the world.

In 2006, a bipartisan band of such politicians in Massachusetts immersed themselves in wishful thinking, ignored both hard facts and proven theory, and used their political muscle to build bureaucracy, increase taxes, and aggregated power to remake health care in the Bay State.

President Obama, House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid took the act nationwide with the passage in March 2010 of the Patient Protection and Affordable Care Act.  Like the canary in a mineshaft, Massachusetts provides a strong indication of our fate.

By now, Bay Staters should be celebrating reform. It promised to benefit all. The bureaucrats would design and broker affordable health plans, doctors and hospitals would get a bump in Medicaid rates, and the uninsured would no longer be a burden.

The system was cracked from the beginning, its promises undelivered even as it picked the pockets of business owners and taxpayers.  The crack turned into a chasm this spring, when the state’s private carriers filed for double-digit rate increases for individual and small group plans.

This incensed Democratic Gov. Duval Patrick and the bureaucrats who simply said no. A court upheld their authority, and carriers were forced to continue at 2009 prices, booking loses daily.

They are still fighting in court, and another ruling is expected on the applications for rate increases on plans this summer.

In early June, two large carriers came back with more double-digit increases for plans renewing in July. They expect them to be declined. They are simply positioning themselves for a two-front war: One with the regulators and one with the providers they pay.

The system is inherently unstable and primed for a series of nasty fights. Like dry season at an Everglades watering hole, all the players confined in a tight space, hungry, and all eyeing the same receding resources.  Like this tight ecosystem, the players will start to feed on each other, as survival of the politically-fittest takes hold.

This is the case in Massachusetts now.  The state’s four largest carriers are hemorrhaging $150 million a month. Roughly a third of contracts are up for negotiation and they are pushing for givebacks.

Providers are crying poor. Reform actually hurt their numbers, as most of the newly-insured enrolled in government-run and subsidized plans under Commonwealth Care that pay less than the actual cost for care.

When you lose money on every unit, you can’t make it up on volume. Traditionally, the cost has been shifted to those with private insurance, but those days are over.

Hospitals and clinic operators maintain that two-thirds of the monies they collect are simply passed on to doctors, nurses, and other essential staff.  Cuts here are akin to cuts in wages. Wage cuts will be resisted.  The unionized will strike. Those who aren’t will slow down on the job. Doctors will reduce their level of service and some will take early retirement.

The political and bureaucratic response is naturally to clamp down with more control. Massachusetts’ political leaders and activists are making a strong push for a structure of mandatory global payments, which is merely a state-dominated HMO or single payer system. This, they claim, is the next logical step of health care reform.

Meanwhile, a bill in the state senate would force doctors to accept cut-rate reimbursements for Medicaid patients as a condition to practice medicine in the state. When voluntary exchange doesn’t work for politicians, they move to conscription.

In Massachusetts, it took four years to get to this point, and it’s certainly a downhill slide from here. Nationally, Obama’s bureaucrats are just getting started.  The administration has yet to comply with the law’s requirement that it detail the myriad of powers it’s been granted, yet it has put the bureaucrats in place to get the job started.

While Obama did not get his Health Insurance Rate Authority into the final bill, the newly-created Office of Consumer Information and Insurance Oversight within HHS will perform the same function.

The new authority has been staffed at the top by four individuals known to be tough on private insurers and more comfortable with the views of Ralph Nader than Adam Smith.

Former Missouri Insurance Commissioner Jay Angoff is the head watchdog. We can expect this team to pick up where Obama and Democrats in Congress left off beating up the insurance carriers including writing regulations to define when premium increases are reasonable.

At the end of the day, the carriers are merely pass-through entities that are necessary to administer the system.  They will probably survive but, like regulated public utilities, will be guaranteed after their Medical Loss Ratios (the percentage that an insurer must pay out in claims) and administrative costs are controlled by government, a modest surplus for their efforts.  The ultimate payers will be consumers and taxpayers, who will either pay more for less or more for nothing at all.  What happens in Mass won’t be staying in Mass.

Sally C. Pipes is president and CEO of the Pacific Research Institute, and author of The Top Ten Myths of American Health Care.

 

Read more at the Washington Examiner: http://www.washingtonexaminer.com/opinion/columns/OpEd-Contributor/Sally-C-Pipes-The-Massachusetts-health-care-mess-is-coming-soon-to-the-rest-of-America-96139829.html#ixzz0qwmWyVpS

The Washington Post (5/27, MacGillis) reports, "The federal government will bear virtually the entire cost of expanding Medicaid under the new health-care law, according to a comprehensive new study by the Kaiser Family Foundation that directly rebuts the loud protests of governors warning about its impact on their strapped state budgets." Notably, "a disproportionate share of the 16 million people expected to enroll in the expanded Medicaid live in states in the South and West that until now have had very stringent eligibility rules for low-income adults. Governors of many of those states have predicted fiscal calamity for their budgets, and some have cited the Medicaid expansion in the suits they have filed against the new law, saying it violates their states' rights."
        Modern Healthcare (5/27, Evans, subscription required) reports that "the largest gains in coverage and federal spending" will occur "in states with low coverage levels and higher numbers of uninsured, the Kaiser Commission on Medicaid and the Uninsured said in newly released state-by-state estimates." The study also indicated that "Medicaid enrollment would increase by 22.8 million and the number of uninsured would drop by 17.5 million."
        Reuters (5/27, Lambert) explains that, according to the study, the federal government will spend an additional $443.5 billion on Medicaid through 2019. In contrast, the states' spending on Medicaid will increase by $21.1 billion, and other types of federal funding will reduce this amount even further. Thus, states such as Maine, Colorado, Massachusetts, and Vermont will reduce Medicaid spending by between 0.5 to 2.1 percent.
        NPR (5/27, Rovner) also points out in its Shots blog, "When 20 states filed suit over the new health law just after President Obama signed it in March, the expansion of Medicaid was a major part of their beef." Yet, "a new study suggests that the Medicaid expansion might cost states less than they think, and some states might actually make money on the deal." In fact, "on average, the federal government will pick up 95.4 percent of each state's expanded costs over that period."
        The San Jose Mercury News (5/27, Zapler) reports, "During the health care debate, Gov. Arnold Schwarzenegger estimated the new law would impose additional costs of $2 billion to $3 billion annually on California once it is fully implemented late this decade." This study estimates, however, "that from 2014 to 2019, as the reform law is ramping up, California could bear additional costs from $3 billion to $6.5 billion over that six-year period." CQ HealthBeat (5/27, subscription required), the Tennessean (5/27, Theobald), the Lafayette (IN) Journal and Courier (5/27, Groppe), Lexington Herald-Leader (5/27, Trumn), and the Mobile Press-Register (5/26, Reilly) also covered the story.

Kaiser Health News -

May. 17: How many times have you heard President Obama say, “Health insurers won’t be able to drop your coverage just because you get sick?” Or Kathleen Sebelius? Or the Democratic leadership in Congress? Or the mainstream news media?
You would think that the private health insurance industry was being revolutionized.

In fact, it has been illegal since 1997, under the Health Insurance Portability and Accountability Act, for insurers to drop coverage because someone gets sick. And even before then, the practice almost never happened.

Think of it this way: Do you think there would be a vibrant, active, ongoing life insurance industry if insurers could renege on their part of the contract after someone dies? How many of us would buy fire insurance if the insurers could change their minds and refuse to pay after our house burns down? Would you buy auto insurance from Allstate if the “good hands” could disappear after a collision occurs?

These things do not happen because:

1. Insurers are contractually obligated to keep their side of the bargain and courts enforce these obligations just like any other contract;

2. Regulatory agencies enforce good behavior, quite apart from any lawsuit, and;

3. An insurer that routinely refused to pay claims would lose customers and go out of business.

So what’s the fuss all about?

It’s about rescissions. This occurs when an insurer cancels a policy and returns the premiums to the policyholder, thus voiding the original contract. It almost always happens because the insurance application form is discovered to have fraudulent, misleading or simply wrong information on it.

Rescissions are very rare. They apply only to the individual market (less than 10% of private health insurance) and even then they occur less than 4/10ths of 1% of the time. Even when it does happen, there is almost always an appeals process where the decision is reviewed by an internal committee and often submitted to outside reviewers. Further, when insurers are wrong as they may sometimes be it is the job of state regulators to correct this injustice.

This has not stopped the Obama administration from demagoguing the issue, however. Based on a Reuters story, Secretary Sebelius accused WellPoint of targeting thousands of female policyholders for rescission after they were diagnosed with breast cancer, and President Obama repeated the charge in his weekend radio address. WellPoint’s response: The insurer paid for 200,000 cases of breast cancer last year and rescinded exactly four policies for fraudulent or misleading statements.

Even though such instances are rare, they can provoke differences of opinion on the proper response. Some cases are fairly straightforward. Suppose on my insurance application I say I am in good health when in fact I have chronic renal failure. Should the insurance company have to pay for my kidney dialysis? Obviously not.

Other cases get murky. Most life insurers will not sell to someone who is obese (girth measurement is often the test). Suppose I lie about this information, then get hit by a truck and killed. Should the insurance have to pay off?

On the one hand, you could argue that the lie I told about my obesity was irrelevant. Yes, I lied. But the lie had no material impact on the cause of my death. On the other hand, my lie was not innocuous. It allowed my family to reap a cash benefit it otherwise would not have been entitled to. It caused the insurer, and therefore the policyholders, to incur a cost they otherwise could have avoided.

Regardless of how you come down on this case, if you find the discussion to be one worth having it is probably because you believe there is economic value in a market for risk in which competition tends to price risk accurately.

Yet this White House does not believe in a market for health care risks. It certainly does not believe in pricing risk accurately. Indeed, they tend to think that the only legitimate function of health insurance companies is to pay medical bills. The reason they think ideal health insurance is a single-payer public plan is because they think government can write checks with less administrative hassle than private companies.

And if the truth were known, I suspect that these views are not confined to health care. I suspect they don’t really believe in a market for any kind of risk.

Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, and sign up for email delivery at kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

By RICARDO ALONSO-ZALDIVAR, Associated Press Writer Ricardo Alonso-zaldivar, Associated Press Writer – Tue May 11, 7:04 pm ET
WASHINGTON – President Barack Obama's new health care law could potentially add at least $115 billion more to government health care spending over the next 10 years, congressional budget referees said Tuesday.

If Congress approves all the additional spending called for in the legislation, it would push the ten-year cost of the overhaul above $1 trillion — an unofficial limit the Obama administration set early on.

The Congressional Budget Office said the added spending includes $10 billion to $20 billion in administrative costs to federal agencies carrying out the law, as well as $34 billion for community health centers and $39 billion for Indian health care.

The costs were not reflected in earlier estimates by the budget office, although Republican lawmakers strenuously argued that they should have been. Part of the reason is technical: the additional spending is not mandatory, leaving Congress with discretion to provide the funds in follow-on legislation — or not.

"Congress does not always act on authorizations that are put into legislation by drafters," explained Kenneth Baer, a spokesman for the White House budget agency. "Authorizations for discretionary spending are not expenditures."

Congressional estimators also said they simply had not had enough time to run the numbers. Costs could go higher, because the legislation authorizes several programs without setting specific funding levels.

The health care law provides coverage to some more than 30 million now uninsured, offering tax credits to help purchase health insurance through new competitive markets that open for business in 2014. When Congress passed the bill in March, the CBO estimated the coverage expansion would cost $938 billion over 10 years, while reducing the federal deficit by $143 billion.

"If Congress were to approve all of this new discretionary funding authorized in the health care bill, almost all of the administration's highly touted savings would be made null and void," said Jennifer Hing, spokeswoman for Republicans on the House Appropriations Committee.

But Baer said Obama would demand that added spending be offset with cuts in other domestic programs. "The president made clear he will enforce that with his veto pen," said Baer.

I often hear from prospective clients, many who just bought online without the advice of a broker, that they did not know how their plan was going to pay until they used it. Often, they have used their plan in a fashion detrimental to their own best interests. So, I want to write this to inform you of some tips for best utilization and pre-emptive planning to reduce costs, aggravation and time when accessing care.

Please share this with your Employees and their loved ones.

Prescription Drug Cost- These are one of the top drivers of cost on a Health plan. Prescriptions are ungodly expensive. Doctors are coddled by the Drug companies to push their new brand drugs often before thorough studies are done to prove favorable outcomes. TIP: Be involved in your care. Ask for generic equivalents. Most plans have a Brand name deductible, so your co-pay will not kick in for the first month’s supply, and probably much longer depending on the plan. So, you end up paying for that medicine to get well. If you get generic, you have two choices. First, you can take your card to the pharmacy and as long as it has Generic coverage, you will simply make the co-pay. Second, go to Walgreens, Walmart, or Costco. Sorry to support the big boxes here, but they have lists of over 500 medications they sell for $4 per month/ $10 for 3 month supply. Hint: Do not show them your insurance card. They will have to charge you the copay of $10-$20.

Urgent Care over Emergency Room-Many people do not plan ahead, thus an accidental injury, or minor illness becomes an emergency. Emergency Rooms are NOT the best place to go for some broken bones and cuts requiring stitches. It is just that since we do not plan ahead, we don’t know where else to go, thus it becomes and Emergency to us. Emergency Rooms prioritize there services based upon need. Emergency Rooms serve those who come in by Ambulance. So, if you drove there, you automatically have lower priority. TIP: Plan ahead…right now, pull out your card and see who you are covered by and go to their website. Look up an Urgent Care Facility near your work and home. Become familiar with both and think of going there first. Emergency Rooms on Individual plans fall under the deductible, so you will be responsible for the whole cost up to your deductible. Group plans cover this better, but there is still the wait time. An Urgent Care facility can treat you faster and with lower costs. Become familiar with them, so when/if something happens, you can consider this faster and less expensive alternative.

I hope these tips will help you.

While the underlying cost of health care services remains an under-reported issue, there are signs that this may be changing (see California and Wisconsin summaries below). The California legislature, for example, is beginning to turn its attention to rising hospital and provider costs, and not just the rising cost of premiums. Just in time, the U.S. Justice Department announced last week that California's largest health care purchasers can proceed with an extensive study  of the costs of care at more than 300 hospitals statewide. The California Hospital Association tried to block the project claiming antitrust concerns, but the Justice Department  rejected the claim. Only by addressing costs throughout the health care system will the nation begin to slow the overall cost of health care and truly deliver on the promise of health care reform. Transparency remains a very important part of the equation.

CALIFORNIA: Democrats on the Senate Health Committee passed legislation addressing greater premium rate transparency. The bill contains numerous problematic provisions that would require detailed actuarial justification for premium increases. However, the bill would also require health insurers to provide hospital and physician price increase information and anticipated trends in reimbursement ratesfor hospitals and other health care providers. With federal reform implementation underway, some legislators are beginning to think about costs in the system and are seeking answers from other stakeholders, rather than just health insurers. The last provision has caught the attention of the state medical society and hospital association.

WISCONSIN: The Governor has signed a transparency bill that requires a health care provider to specify charge information for diagnosing and treating 25 presenting conditions: the provider's median billed charges; the reimbursement amount under Medical Assistance; the reimbursement amount under Medicare; and the average allowable payment from private, third-party payers. This applies to health care facilities including hospitals, ambulatory surgical centers or nursing homes, and to associations of providers that include four or more practitioners.  The law also requires a self-insured health plan of the state, county, city, village, town, or school district, and insurers providing coverage under a health insurance policy to provide, upon request, to an insured a good faith estimate of the enrollee’s total out-of-pocket cost for a specified health care service in the geographic region in which the service will be provided. The estimate is not legally binding. 

USA Today (4/29, Young) reports, "About 200,000 Americans whose illnesses have kept them from getting regular health insurance will not be allowed to enroll this summer in a new lower cost federal program for people like them because they already buy pricey state-run plans." USA Today adds, "The nation's new health law creates a far cheaper insurance program opening July 1 for people with pre-existing medical conditions. To qualify, a person can't have had health coverage for six months." As a result, "it excludes people already enrolled in 35 state high-risk pools offering insurance of last resort. The state pools charge high premiums...to help cover costs." HHS spokeswoman Jenny Backus "said the federal pools are a temporary fix to help uninsured people with pre-existing conditions get coverage until 2014."

I trust this is an unintended result of their efforts. Those who sought safety in state high risk pools already cannot get on the new mandated Federal program....hmmm

By Duke Helfand, Los Angeles Times
 
April 24, 2010

Tom Taylor learned a lesson about healthcare finances when he had both his knees replaced a couple of months apart at separate hospitals in Northern California.

The tab at the first hospital was $95,000, but the second cost $55,000. The same doctor performed identical surgeries on both knees, and Taylor says he can't detect any differences between the two.

More... http://tinyurl.com/2aqq8uq