HR 3962 assures that children with congenital or developmental deformities be covered under group health plans. But children born to a "covered" parent already have these benefits. The question is - who will benefit from this rule change?
It is quite popular for those who would like to adopt children to go abroad to do so. Many choose to adopt a child with special needs, such as a cleft palate, who would be less likely to be adopted by a local couple. These children may require one or several surgeries as they grow. No doubt, this is a noble and charitable deed. This is not an unknown risk, the parents had full disclosure of the condition when they adopted the child. Often employer health plans willingly choose to extend coverage for such conditions under their plan in these circumstances. Understanding that such generous coverage necessitates higher premiums to pay for it, the question is should an employer-provided health plan be forced to participate in the employee's charity? Health plans do not typically cover adoption as part of their reproductive health options coverage. Parents pay tens of thousands of dollars of their own savings to adopt. Is it unreasonable for them to bear the full
expense of their decisions, rather than mandate it be cost-shifted to their employers, particularly in these difficult economic times?
This does not need to preclude parents from adopting a child with congenital or developmental deformities. Today, many developing countries have first-world internationally accredited hospitals where these children can have the necessary procedures at a tiny fraction of what it would cost for the same care here. It may be easier for the child and parents, given the staff speak the child's native language, as well as English.
Friday, November 27, 2009
Thursday, November 26, 2009
Wednesday, November 25, 2009
HR 3962: Domestic Violence - No Longer PreExisting: Is This Enabling?
Clearly, a first case of domestic violence should be covered under any health plan. The question is how many times should a person let someone beat the daylights out of them and a third party be forced to pay for their care? Given that mental health coverage is unlimited under this bill, shouldn't there be some personal responsibility on the part of the patient to get the help they need to assure this doesn't happen again? Would it not seem reasonable that if this person is seeking treatment and another episode occurs, it should be covered,
but any subsequent costs incurred as a result of abuse should be the patient's responsibility? To force insurers and employers to continue covering the costs of domestic violence makes them in essence a facilitator of abuse. Does this really help the patient come to terms with the situation?
but any subsequent costs incurred as a result of abuse should be the patient's responsibility? To force insurers and employers to continue covering the costs of domestic violence makes them in essence a facilitator of abuse. Does this really help the patient come to terms with the situation?
Monday, November 23, 2009
HR 3962: Why is Government Insuring the Already Well-Insured?
HR 3962 provides current retirees with protection against reductions in retiree health benefits now offered by companies or employee organizations. Historically, this has been a popular benefit with unionized companies, particularly in manufacturing. This bill does not mean that such plans must continue the same benefits for current employees. Most retiree health plans will not be able to as they tend to be underfunded given usage patterns and health status. With the Cadillac health plans provided, these employees are accustomed to going to the doctor for every sniffle. These retirees also tend to have metabolic syndrome - obesity, diabetes and hypertension, as well as, cardiovascular disease and tend to need joint replacements to a greater degree than the general population.
However, retirees need not worry because under this bill the US government becomes the reinsurer of retiree health benefits. This means the US taxpayer will underwrite future benefits for these folks. Here's how it works: If the retiree has a large claim, the plan will pay the first $15 thousand in medical expenses. The government will pay 80% of the next $75 thousand in claims up to $90 thousand in claims. If there is a $90 thousand claiming a given year, the US Government will reimburse the plan $60 thousand or in this example 2/3 of the costs. Benefits will be paid from the Retiree Reserve Trust Fund, with $10 billion from the US Treasury. It would seem these people are better off than most retirees. What reason would our politicians in Washington have for being so generous with our tax dollars for people who already have retiree health benefits?
According to this legislation, the DHHS Secretary can stop taking applications for participation in the program or reduce payouts at any time to ensure the government reinsurance program does not exceed the appropriated funds. This gives the government considerable leverage over private retiree health plans. It also gives the government considerable leeway in how to administer the trust fund, who may receive reimbursement and at what levels should the fund run out of funds. Given this $10 billion is a one time appropriation according to the CBO budget analysis (Page 11), what happens when the money does run out? This would seem to place the current politicians in Congress in a powerful position for future elections with one of the most active and well-mobilized voting blocks.
However, retirees need not worry because under this bill the US government becomes the reinsurer of retiree health benefits. This means the US taxpayer will underwrite future benefits for these folks. Here's how it works: If the retiree has a large claim, the plan will pay the first $15 thousand in medical expenses. The government will pay 80% of the next $75 thousand in claims up to $90 thousand in claims. If there is a $90 thousand claiming a given year, the US Government will reimburse the plan $60 thousand or in this example 2/3 of the costs. Benefits will be paid from the Retiree Reserve Trust Fund, with $10 billion from the US Treasury. It would seem these people are better off than most retirees. What reason would our politicians in Washington have for being so generous with our tax dollars for people who already have retiree health benefits?
According to this legislation, the DHHS Secretary can stop taking applications for participation in the program or reduce payouts at any time to ensure the government reinsurance program does not exceed the appropriated funds. This gives the government considerable leverage over private retiree health plans. It also gives the government considerable leeway in how to administer the trust fund, who may receive reimbursement and at what levels should the fund run out of funds. Given this $10 billion is a one time appropriation according to the CBO budget analysis (Page 11), what happens when the money does run out? This would seem to place the current politicians in Congress in a powerful position for future elections with one of the most active and well-mobilized voting blocks.
Thursday, November 19, 2009
Where has opportunity gone?
While we wait to get a copy of the actual final Senate bill - Last week Senator Harry Reid was reportedly debating another proposed tax increase on those earning more than $250,000 per year to pay for the Senate healthcare proposal; it now appears to have been included in the final version. This time it is an increase in the Medicare payroll tax rate. [NYTimes]
It is extremely popular these days for politicians to consider taxing high income earners. This is perhaps not the wisest move from a tax standpoint, since the top 1% paid 39% of all individual income taxes according to CNN. Let us consider why most people or their families immigrated to this country in the first place – it was the land of opportunity.
Economist Richard Florida wrote about this phenomenon in his critically acclaimed book The Rise of the Creative Class, which describes the immigrant draw of cities like Pittsburgh in the industrial age. His sequel, The Flight of the Creative Class is a must read for any thinking person today. [For a taste, read the brief in the Harvard Business Review.] He calls the doctors, lawyers, engineers, scientists, architects, artists, musicians and professors the creative class. He says that it is America’s openness to new people, ideas and the opportunity to succeed that attracted the world’s talent to our shores. He also documents the social change that has occurred in this country over the last 20 years and the reasons why America appears to have lost some of its luster. Now, it seems our politicians are determined to punish our most productive workers. The question is, if this country continues down this path, why should the creative class remain here? These are people with desirable transferrable skills who can live and work anywhere in the world – But what does this have to do with healthcare?
At a medical conference less than two weeks ago, a physical medicine and rehab physician was telling me he was watching this healthcare debate and depending how it went, looking at potentially moving to New Zealand. He had no idea I had been working with the osteopathic medical profession for the last 10 years on expanding the opportunities for the profession; he was telling me where we had practice rights. But it does not end there, my own family practitioner and her husband, an internist, took a trip this spring to investigate a few countries where they thought might be a good place to live and work. None of these folks are international types, yet they are looking uproot their families and move to another country for a better opportunity. Sure, this is anecdotal evidence now; but in two years, given the current political trajectory, there will be objective studies to show the exodus of the creative class. In less than four years, it will be common knowledge. It is time our politicians wake up before we lose our talent and our tax base.
It is extremely popular these days for politicians to consider taxing high income earners. This is perhaps not the wisest move from a tax standpoint, since the top 1% paid 39% of all individual income taxes according to CNN. Let us consider why most people or their families immigrated to this country in the first place – it was the land of opportunity.
Economist Richard Florida wrote about this phenomenon in his critically acclaimed book The Rise of the Creative Class, which describes the immigrant draw of cities like Pittsburgh in the industrial age. His sequel, The Flight of the Creative Class is a must read for any thinking person today. [For a taste, read the brief in the Harvard Business Review.] He calls the doctors, lawyers, engineers, scientists, architects, artists, musicians and professors the creative class. He says that it is America’s openness to new people, ideas and the opportunity to succeed that attracted the world’s talent to our shores. He also documents the social change that has occurred in this country over the last 20 years and the reasons why America appears to have lost some of its luster. Now, it seems our politicians are determined to punish our most productive workers. The question is, if this country continues down this path, why should the creative class remain here? These are people with desirable transferrable skills who can live and work anywhere in the world – But what does this have to do with healthcare?
At a medical conference less than two weeks ago, a physical medicine and rehab physician was telling me he was watching this healthcare debate and depending how it went, looking at potentially moving to New Zealand. He had no idea I had been working with the osteopathic medical profession for the last 10 years on expanding the opportunities for the profession; he was telling me where we had practice rights. But it does not end there, my own family practitioner and her husband, an internist, took a trip this spring to investigate a few countries where they thought might be a good place to live and work. None of these folks are international types, yet they are looking uproot their families and move to another country for a better opportunity. Sure, this is anecdotal evidence now; but in two years, given the current political trajectory, there will be objective studies to show the exodus of the creative class. In less than four years, it will be common knowledge. It is time our politicians wake up before we lose our talent and our tax base.
Tuesday, November 17, 2009
USPSTF: Rationing or Rational Use of Screening Tools for Detecting Breast Cancer
Yesterday, the US Guide to Preventive Services released the latest guidelines on breast cancer screening recommendations. The press went wild and said this was government rationing of preventive testing. The "US Guide to Preventive Services Task Force Guidelines show stark differences of opinion with the specialty groups regarding screening, diagnostic and treatment methods. When the numbers came in, physicians following specialty colleges' recommendations were overtesting, overtreating and unnecessarily worrying patients. The research did not back up the specialty standards." Most of these recommendations are by convention rather than by scientific medical evidence.
Let's set the record straight - The USPSTF never recommended routine screening at 40 - there was insufficient evidence to recommend for or against routine mammography or clinical breast exams in the 40-49 y.o. age group for the general population - NOTHING CHANGED. It was the specialty & disease societies such as American Cancer Society, AMA and American College of Obstetrics and Gynecology that made these recommendations. Other groups, such as the American College of Physicians, said it should be based on the risk of the individual patient. It should always be based on the individual patient's need - these are population guidelines - of course, the patient in front of you may have different needs.
What did change? The 2002 Guidelines said mammography every 1-2 years was recommended for women age 50-69y.o., although recommendations for high risk women 40-49 and healthy women > or = 70 may be made on other grounds. Today's Guidelines say: Mammography screening is recommended every 2 years for women age 50-74. The USGPSTF is recommending screening for a LONGER period of time, NOT less.
Why every two years screening? Because mammograms are not benign - they expose a patient to radiation. The USPSTF also says "Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." Subsequent biopsies will change the breast architecture and make it more difficult to interpret future exams. Evidence also shows that the more mammograms a woman has the more likely she will have a "false-positive" mammogram. According to a Harvard Pilgrim Healthcare study in the Journal of the National Cancer Institute which followed women over a 10-year period with "9747 screening mammograms, 6. 5% were false-positive; 23.8% of women experienced at least one false-positive result. After nine mammograms, the risk of a false-positive mammogram was 43.1%." Clearly more diagnostic testing does NOT equate to higher quality medical care.
Let's set the record straight - The USPSTF never recommended routine screening at 40 - there was insufficient evidence to recommend for or against routine mammography or clinical breast exams in the 40-49 y.o. age group for the general population - NOTHING CHANGED. It was the specialty & disease societies such as American Cancer Society, AMA and American College of Obstetrics and Gynecology that made these recommendations. Other groups, such as the American College of Physicians, said it should be based on the risk of the individual patient. It should always be based on the individual patient's need - these are population guidelines - of course, the patient in front of you may have different needs.
What did change? The 2002 Guidelines said mammography every 1-2 years was recommended for women age 50-69y.o., although recommendations for high risk women 40-49 and healthy women > or = 70 may be made on other grounds. Today's Guidelines say: Mammography screening is recommended every 2 years for women age 50-74. The USGPSTF is recommending screening for a LONGER period of time, NOT less.
Why every two years screening? Because mammograms are not benign - they expose a patient to radiation. The USPSTF also says "Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups." Subsequent biopsies will change the breast architecture and make it more difficult to interpret future exams. Evidence also shows that the more mammograms a woman has the more likely she will have a "false-positive" mammogram. According to a Harvard Pilgrim Healthcare study in the Journal of the National Cancer Institute which followed women over a 10-year period with "9747 screening mammograms, 6. 5% were false-positive; 23.8% of women experienced at least one false-positive result. After nine mammograms, the risk of a false-positive mammogram was 43.1%." Clearly more diagnostic testing does NOT equate to higher quality medical care.
Who is the US Preventive Services Task Force?
The past 24 hours I have heard at least a dozen media pundits commenting on when breast cancer screening should or shouldn’t be done. Apparently most seem to think that disease and specialty societies trump the US PSTF. They have bashed “government bureaucrats” who are apparently trying “to deny women care.”
Let’s understand the nature of this Task Force – It is lead by the Agency for Healthcare Research and Quality (AHRQ). All members reviewing breast cancer screeening, save the two PhD nurses, are physician experts, from various specialty colleges, academia and public health service; the majority also have public health degrees in addition. “Federal partners include the Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), Centers for Medicare and Medicaid Services (CMS), Department of Veterans Affairs (VA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), U.S. Army Center for Health Promotion and Preventive Medicine, and the U.S. Food and Drug Administration (FDA). Primary care partners include the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Preventive Medicine, America's Health Insurance Plans, the Canadian Task Force on Preventive Health Care, the National Committee for Quality Assurance, and the Pan American Health Organization.” [1]
“The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services. [Here are the methods.] The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Recommendations issued by the USPSTF are intended for use in the primary care setting… to present health care providers with…the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.” [2]
No other organization goes through such a rigorous examination of the evidence for clinical recommendations for the asymptomatic general population. These recommendations are obviously different than for a patient who is symptomatic, has a family history or would otherwise be considered high risk. It is also important to understand and weigh the capabilities, limitations, benefits and potential harms of a given screening test. The distinction not being made by the press is the difference between population medicine versus care of the individual patient.
Let’s understand the nature of this Task Force – It is lead by the Agency for Healthcare Research and Quality (AHRQ). All members reviewing breast cancer screeening, save the two PhD nurses, are physician experts, from various specialty colleges, academia and public health service; the majority also have public health degrees in addition. “Federal partners include the Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), Centers for Medicare and Medicaid Services (CMS), Department of Veterans Affairs (VA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), U.S. Army Center for Health Promotion and Preventive Medicine, and the U.S. Food and Drug Administration (FDA). Primary care partners include the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Preventive Medicine, America's Health Insurance Plans, the Canadian Task Force on Preventive Health Care, the National Committee for Quality Assurance, and the Pan American Health Organization.” [1]
“The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services. [Here are the methods.] The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Recommendations issued by the USPSTF are intended for use in the primary care setting… to present health care providers with…the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.” [2]
No other organization goes through such a rigorous examination of the evidence for clinical recommendations for the asymptomatic general population. These recommendations are obviously different than for a patient who is symptomatic, has a family history or would otherwise be considered high risk. It is also important to understand and weigh the capabilities, limitations, benefits and potential harms of a given screening test. The distinction not being made by the press is the difference between population medicine versus care of the individual patient.
Monday, November 16, 2009
Electronic Medical Records:Marginal Quality of Care & Length of Stay Benefits
Today's New York Times contains an article about Boston area hospitals entitled “Little benefit seen so far in electronic patient records.” At present, less than 2% of hospitals and less than 13% of offices have electronic medical resords (EMR) systems. Few of these are comprehensive systems with scheduling, patient intake information, consult notes, nursing notes, labs/diagnostics and billing, etc. The federal government has designated $19 billion in TARP money to help physicians and hospitals make the conversion claiming cost savings and improved patient care.
It seems finally we have the empiric evidence to support what medical professionals have long suspected – that EMRs do NOT translate to better hospital care or shorter lengths of stay. So why should a doctor's office spend $40-60 thousand plus $20 thousand annually in licensing fees for such a system? Why should a hospital system spend tens of millions and up to $100 million to implement such a system? Where is the return on investment?
There are four main issues in implementing electronic medical records.
1.These systems cost a lot of money.
2.The purchasers of EMRs are not the ones to reap the benefits of the system; benefits accrue to the patients, employers, insurers and government.
3.There is no readily exchangable format, as there is no off-the-shelf Microsoft Office version of EMRs that works well for the various specialties and levels of hospital care.
4.There is no means of readily assembling the patient's complete medical record from all sources from which they have sought care when they are sitting on the examining table in front of you.
The benefits of EMRs often touted are elimination of waste, fraud and abuse of the healthcare system. Yes, EMRs could decrease the costs of defensive medicine, estimated at 5-9% of total medical expenditures. They could decrease the need for repeated testing , lower perscription expenditures, facilitate authorization for procedures, verify services provided, shorten payment time, etc. But this does not necessarily occur just because an office or hospital has an EMR in place. There must be a way to access and assemble a complete record when needed. We don't need necessarily EMRs, what we really need is an electronic medical filing cabinet. Similar to the way the credit bureaus assemble financial records, we need a way for verified credentialed providers of healthcare to access the system when a patient is biometrically identified in their office. While the intricate details are too much for a blog, suffice it to say it could be done for the price of a print scanner and biometric scanner at a penny or so per transaction. [See Chapter 5 of Healthcare Solved, if you are curious for more details.]
It seems finally we have the empiric evidence to support what medical professionals have long suspected – that EMRs do NOT translate to better hospital care or shorter lengths of stay. So why should a doctor's office spend $40-60 thousand plus $20 thousand annually in licensing fees for such a system? Why should a hospital system spend tens of millions and up to $100 million to implement such a system? Where is the return on investment?
There are four main issues in implementing electronic medical records.
1.These systems cost a lot of money.
2.The purchasers of EMRs are not the ones to reap the benefits of the system; benefits accrue to the patients, employers, insurers and government.
3.There is no readily exchangable format, as there is no off-the-shelf Microsoft Office version of EMRs that works well for the various specialties and levels of hospital care.
4.There is no means of readily assembling the patient's complete medical record from all sources from which they have sought care when they are sitting on the examining table in front of you.
The benefits of EMRs often touted are elimination of waste, fraud and abuse of the healthcare system. Yes, EMRs could decrease the costs of defensive medicine, estimated at 5-9% of total medical expenditures. They could decrease the need for repeated testing , lower perscription expenditures, facilitate authorization for procedures, verify services provided, shorten payment time, etc. But this does not necessarily occur just because an office or hospital has an EMR in place. There must be a way to access and assemble a complete record when needed. We don't need necessarily EMRs, what we really need is an electronic medical filing cabinet. Similar to the way the credit bureaus assemble financial records, we need a way for verified credentialed providers of healthcare to access the system when a patient is biometrically identified in their office. While the intricate details are too much for a blog, suffice it to say it could be done for the price of a print scanner and biometric scanner at a penny or so per transaction. [See Chapter 5 of Healthcare Solved, if you are curious for more details.]
Thursday, November 12, 2009
HR 3962: Extension of Coverage vs. States Rights
HR 3962, Sec. 105 allows parents to keep their adult children under 27 years of age, who may or may not be in school or working, and are not enrolled in a health plan, enrolled under their parent's health plan. [Of course, the parent and the parent’s employer will pay the added premium for keeping the additional family member on the plan.] At present, state laws have varying ages and conditions under which children may be kept on their parent’s plan. This bill, however, nationalizes those requirements. It is interesting that Congress can nationalize administrative rules previously under the prerogative of the states to increase insurance coverage for Americans; however, Congress is unwilling to use the same logic to open up competition with a national health insurance market, a move that would significantly lower rates in many markets. If the idea is to get more people covered, wouldn’t making cheaper insurance coverage available to more people, more places be a good start?
Wednesday, November 11, 2009
HR 3962: Mental Health Parity is the End of Disability Insurance
Until HR 3962, mental health conditions were subject to a plan’s limits. While this change will no doubt have the effect of dramatically increasing healthcare expenditures, it will have catastrophic effects on the disability insurance industry. In fact, it will virtually eliminate it entirely within about 2 years.
Disability insurance is income insurance if you are sick or otherwise unable to work. Typically, there is a two-year limit on mental nervous illnesses. The thought is - if there is a problem, this should give the person adequate time to get the help they need to recover. Presumably, if a person was capable of working before, that person should be able to be treated.
There are a few things that one must understand about this product: Disability claims routinely go up when the economy goes down. They also rise when a given employer is having financial difficulties and the fear of layoffs is real. Not too surprisingly mental-nervous conditions top the claims list, with depression or anxiety leading the pack. In fact, if employees know it is likely that they will be laid off or given a pink slip, it is not uncommon for them to take preemptive action to assure their income by claiming disability. Since all it takes is a healthcare provider’s note to get the process started, some employees will have their provider write a note the very day they are laid off. Keep in mind, full benefits are good till the end of the day.
As the former Chief Medical Officer for a global disability and workers’ compensation carrier who has reviewed thousands of disability claims, this is what you will commonly see: Providers often refuse to release psychiatric notes claiming patient privacy, despite signed releases for exactly such records. They will often re-write office notes or summarize notes so that insurers do not know what treatment has been given. In fact, there is great variability and little coordination of the treatment that is given. Anyone from a licensed social worker, psychologist, masters level psychologist, masters level degree in counseling, doctoral psychologist, neuropsychologist, psychiatrist, family practioner, physician’s assistant or nurse practitioner may be “treating” the person.
Many times the mental-nervous issues are situational, in which work often helps, but little or no tools are given to the patient as to how to better cope, other than to write them off work. It seems patients often spend their sessions rehashing their problems. There is no documentation of actual counsel given or progress made. In medicine, if it isn’t written in the medical records, it wasn’t done. Often little or no objective testing has been done to determine exactly what the diagnosis is, or if it is even real, versus secondary gain – such as a disability check. Many real physical conditions never receive a full medical work-up. As with other conditions in medicine, medical personnel often add to the prescriptive regimen without checking to see if the medical regimen is causing the problem. Another important issue is the number of people diagnosed with personality disorders in the workplace. There is a prevailing notion that these diagnoses preclude people from working, when in fact many are capable of functioning at a very high level; the issue is how they relate to others, not whether they have the actual knowledge base to do the job.[See the article Personality Disorders in the Workplace.] Granted some disorders are more amenable to treatment than others, however, quite a number of those in the mental health field seem to think these diagnoses are a lifetime pass.
Due to the delays from providers and frequent lack of objective evidence or testing, it takes thousands of dollars and months of time to prove the whether or not the disability is legitimate. The two-year limit at least puts a tail on it for employers and insurers. This bill will mean a guaranteed income to age 65 for the insured who finds a cooperative provider or switches providers often enough to keep the insurer a couple of steps behind. Given the outlook for the economy and this legislation, no good company will be able to afford to continue to provide this valuable benefit to their employees. No disability insurer will be able to continue to stay in business if HR 3962 passes the Senate. Instead, expect disability carriers to stop renewing policies and begin liquidating operations in the coming year.
Disability insurance is income insurance if you are sick or otherwise unable to work. Typically, there is a two-year limit on mental nervous illnesses. The thought is - if there is a problem, this should give the person adequate time to get the help they need to recover. Presumably, if a person was capable of working before, that person should be able to be treated.
There are a few things that one must understand about this product: Disability claims routinely go up when the economy goes down. They also rise when a given employer is having financial difficulties and the fear of layoffs is real. Not too surprisingly mental-nervous conditions top the claims list, with depression or anxiety leading the pack. In fact, if employees know it is likely that they will be laid off or given a pink slip, it is not uncommon for them to take preemptive action to assure their income by claiming disability. Since all it takes is a healthcare provider’s note to get the process started, some employees will have their provider write a note the very day they are laid off. Keep in mind, full benefits are good till the end of the day.
As the former Chief Medical Officer for a global disability and workers’ compensation carrier who has reviewed thousands of disability claims, this is what you will commonly see: Providers often refuse to release psychiatric notes claiming patient privacy, despite signed releases for exactly such records. They will often re-write office notes or summarize notes so that insurers do not know what treatment has been given. In fact, there is great variability and little coordination of the treatment that is given. Anyone from a licensed social worker, psychologist, masters level psychologist, masters level degree in counseling, doctoral psychologist, neuropsychologist, psychiatrist, family practioner, physician’s assistant or nurse practitioner may be “treating” the person.
Many times the mental-nervous issues are situational, in which work often helps, but little or no tools are given to the patient as to how to better cope, other than to write them off work. It seems patients often spend their sessions rehashing their problems. There is no documentation of actual counsel given or progress made. In medicine, if it isn’t written in the medical records, it wasn’t done. Often little or no objective testing has been done to determine exactly what the diagnosis is, or if it is even real, versus secondary gain – such as a disability check. Many real physical conditions never receive a full medical work-up. As with other conditions in medicine, medical personnel often add to the prescriptive regimen without checking to see if the medical regimen is causing the problem. Another important issue is the number of people diagnosed with personality disorders in the workplace. There is a prevailing notion that these diagnoses preclude people from working, when in fact many are capable of functioning at a very high level; the issue is how they relate to others, not whether they have the actual knowledge base to do the job.[See the article Personality Disorders in the Workplace.] Granted some disorders are more amenable to treatment than others, however, quite a number of those in the mental health field seem to think these diagnoses are a lifetime pass.
Due to the delays from providers and frequent lack of objective evidence or testing, it takes thousands of dollars and months of time to prove the whether or not the disability is legitimate. The two-year limit at least puts a tail on it for employers and insurers. This bill will mean a guaranteed income to age 65 for the insured who finds a cooperative provider or switches providers often enough to keep the insurer a couple of steps behind. Given the outlook for the economy and this legislation, no good company will be able to afford to continue to provide this valuable benefit to their employees. No disability insurer will be able to continue to stay in business if HR 3962 passes the Senate. Instead, expect disability carriers to stop renewing policies and begin liquidating operations in the coming year.
Tuesday, November 10, 2009
HR 3962: Pre-existing condition or war injury?
Unless you have been out of the country or trapped under the cone of silence, you have no doubt heard that the House of Representatives narrowly passed HR 3962 – the Affordable Healthcare for America Act – Saturday night, 220 to 215. There are many issues in this bill that it seems both healthcare organizations and the media either haven’t read or didn’t understand. We will address them point by point over the next week or so.
Let us begin today by looking at those pesky pre-existing conditions...
SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.
As written, the burden of caring for our injured war veterans is lifted off the shoulders of the Veterans Administration and places it squarely on the backs of private insurers as our veterans transition back into society. Due to the rapid emergency medical response of our military, we have not had the number of deaths in Iraq & Afghanistan that we have in other wars; but we have had more injuries that previously would have killed our troops. Consequently, many have needed prosthetics and extensive rehabilitation. Good prosthetics cost tens of thousands of dollars and robotic prosthetics (hands that work like hands, such as the DEKA arm, rather than a hook) are near six figures.
This bill also provides for mental health parity. This means private insurers cannot limit mental health benefits. Given that in combination with the pre-ex elimination, the VA can also shift its mental health counseling to the private sector. With many of our troops having had multiple tours of duty, it should not be surprising that they will need some assistance readjusting back to civilian life. When vets get care at the VA, it is easier to gather data for researching what care works best and implement current standard of care treatment. In the private sector, this is much more difficult as it means educating all possible providers who may have varied or no experience treating vets.
In March, Uncle Sam floated the idea of having private insurers reimburse the Veterans Administration for care for service-related injuries. [Washington Post] After protests from veterans groups, the executive branch appeared to back off. Under this bill, House has managed to get the government off the hook again for its obligations to our wounded heroes. This is morally reprehensible.
Let us begin today by looking at those pesky pre-existing conditions...
SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.
As written, the burden of caring for our injured war veterans is lifted off the shoulders of the Veterans Administration and places it squarely on the backs of private insurers as our veterans transition back into society. Due to the rapid emergency medical response of our military, we have not had the number of deaths in Iraq & Afghanistan that we have in other wars; but we have had more injuries that previously would have killed our troops. Consequently, many have needed prosthetics and extensive rehabilitation. Good prosthetics cost tens of thousands of dollars and robotic prosthetics (hands that work like hands, such as the DEKA arm, rather than a hook) are near six figures.
This bill also provides for mental health parity. This means private insurers cannot limit mental health benefits. Given that in combination with the pre-ex elimination, the VA can also shift its mental health counseling to the private sector. With many of our troops having had multiple tours of duty, it should not be surprising that they will need some assistance readjusting back to civilian life. When vets get care at the VA, it is easier to gather data for researching what care works best and implement current standard of care treatment. In the private sector, this is much more difficult as it means educating all possible providers who may have varied or no experience treating vets.
In March, Uncle Sam floated the idea of having private insurers reimburse the Veterans Administration for care for service-related injuries. [Washington Post] After protests from veterans groups, the executive branch appeared to back off. Under this bill, House has managed to get the government off the hook again for its obligations to our wounded heroes. This is morally reprehensible.
Thursday, November 5, 2009
HR 3961, HR 3962, the Medicare SGR & the Debt
We are still awaiting the CBO's scoring of the bill which came out of the Senate majority leader's closed door discussions. Similar to the "bill" sent to the CBO by the Senate Finance Committee, it is still in the conceptual stage and has yet to be officially written.
On the other hand, the bills in the House were merged to form H.R. 3962, the Affordable Health Care for America Act, which was released October 29th. As mentioned in the analysis of the Baucus Bill, H.R. 3962 does not include fixing the physician reimbursement rate (Medicare SGR). While it claims to save the federal government $104 billion, it leaves in place the 21% SGR cut scheduled for 2010, and makes no further provisions to fix the formula. This is clearly unsustainable, as providers will have no choice but to opt out of the program, leaving seniors without care.
Interestingly a separate bill, H.R.3961, the Medicare Physician Payment Reform Act of 2009, was introduced the same day. It restructures the SGR formula, increasing physician payments for Medicare, Medicare Advantage and TRICARE. One quarter of that increase would come from premium increases paid by Medicare Part B enrollees. Ultimately, this bill is estimated to increase the direct spending of the Federal government by $210 billion over the 2010-2019 period.
According to the numbering system, it seems the Medicare Physician Payment Reform Bill was introduced first. It seems someone in the House was aware of the SGR problem. Since this wasn't an afterthought, wouldn't it have been logical to have “fixed” the problem in the comprehensive bill before introducing it? After all, for months politicians have been insisting that we must have ONE bill to reform healthcare. But without the "fix," House politicians could and did proceed to hold press conferences, claiming victory and “savings” for the American people all the while putting us $100+ billion further in debt. This behavior is disrespectful of the hardworking Americans who voted them into office and it does nothing to increase sustainability or affordability.
On the other hand, the bills in the House were merged to form H.R. 3962, the Affordable Health Care for America Act, which was released October 29th. As mentioned in the analysis of the Baucus Bill, H.R. 3962 does not include fixing the physician reimbursement rate (Medicare SGR). While it claims to save the federal government $104 billion, it leaves in place the 21% SGR cut scheduled for 2010, and makes no further provisions to fix the formula. This is clearly unsustainable, as providers will have no choice but to opt out of the program, leaving seniors without care.
Interestingly a separate bill, H.R.3961, the Medicare Physician Payment Reform Act of 2009, was introduced the same day. It restructures the SGR formula, increasing physician payments for Medicare, Medicare Advantage and TRICARE. One quarter of that increase would come from premium increases paid by Medicare Part B enrollees. Ultimately, this bill is estimated to increase the direct spending of the Federal government by $210 billion over the 2010-2019 period.
According to the numbering system, it seems the Medicare Physician Payment Reform Bill was introduced first. It seems someone in the House was aware of the SGR problem. Since this wasn't an afterthought, wouldn't it have been logical to have “fixed” the problem in the comprehensive bill before introducing it? After all, for months politicians have been insisting that we must have ONE bill to reform healthcare. But without the "fix," House politicians could and did proceed to hold press conferences, claiming victory and “savings” for the American people all the while putting us $100+ billion further in debt. This behavior is disrespectful of the hardworking Americans who voted them into office and it does nothing to increase sustainability or affordability.
Monday, November 2, 2009
Medicare, Medicare Supplemental & Medicare Advantage: Part III - Who enrolls in what plan?
A 2005 report by Emory University researchers and commissioned by the Blue Cross Blue Shield Association of America found the following:
Of eligible retirees, 18% percent only have Medicare coverage. It is important to note that 49% of African-Americans and 31% of Hispanics and 33% of Whites fall into this category. Over 30% of retirees have primary or supplemental coverage through employer or union retirement plans. Another 25% of those who are Medicare eligible purchase MedSup (Medigap) policies on their own. Another 13% are Medicare beneficiaries who are also on Medicaid or other public assistance plans. Medicare Advantage covers 13% of retirees (Today, this represents 10 million people.)
Of retirees without employer/union plans or Medicaid, 53% of Hispanics, 40% of African- Americans and 33% of whites are enrolled in Medicare Advantage plans.
Medicare Advantage plans are required to offer at minimum the same benefits as traditional Medicare. Many offer more coverage, including vision, dental and drug benefits. As a result, those with lower incomes (<$20,000) are quick to see the value in joining such programs. In fact, 18% of Medicaid eligible retirees join a Medicare Advantage program instead of Medicaid. [One wonders if this is because of the challenges in signing up for public assistance or because Medicare Advantage is preferred.] It was determined that Medicare Advantage plans provided a $1,128 per person savings to the state and federal government over Medicaid. According to the study, if Medicare Advantage was ended, 39% would join a MedSup plan. Another 39% would be left with only basic Medicare and 22% would join Medicaid. As discussed in the October 29th post, Congress is subsidizing benefits for Medicare Advantage enrollees. Poor and minority groups are disproportionately affected if these are eliminated. Since Medicare Advantage is more cost-efficient than Medicaid and has a 90+% satisfaction rate, perhaps there ought to be some means testing to qualify for these private sector programs. From a cost standpoint, perhaps would it be reasonable for government to encourage elderly Medicaid enrollees, in geographic areas where plans exist, to enroll in Medicaid Advantage programs.
Of eligible retirees, 18% percent only have Medicare coverage. It is important to note that 49% of African-Americans and 31% of Hispanics and 33% of Whites fall into this category. Over 30% of retirees have primary or supplemental coverage through employer or union retirement plans. Another 25% of those who are Medicare eligible purchase MedSup (Medigap) policies on their own. Another 13% are Medicare beneficiaries who are also on Medicaid or other public assistance plans. Medicare Advantage covers 13% of retirees (Today, this represents 10 million people.)
Of retirees without employer/union plans or Medicaid, 53% of Hispanics, 40% of African- Americans and 33% of whites are enrolled in Medicare Advantage plans.
Medicare Advantage plans are required to offer at minimum the same benefits as traditional Medicare. Many offer more coverage, including vision, dental and drug benefits. As a result, those with lower incomes (<$20,000) are quick to see the value in joining such programs. In fact, 18% of Medicaid eligible retirees join a Medicare Advantage program instead of Medicaid. [One wonders if this is because of the challenges in signing up for public assistance or because Medicare Advantage is preferred.] It was determined that Medicare Advantage plans provided a $1,128 per person savings to the state and federal government over Medicaid. According to the study, if Medicare Advantage was ended, 39% would join a MedSup plan. Another 39% would be left with only basic Medicare and 22% would join Medicaid. As discussed in the October 29th post, Congress is subsidizing benefits for Medicare Advantage enrollees. Poor and minority groups are disproportionately affected if these are eliminated. Since Medicare Advantage is more cost-efficient than Medicaid and has a 90+% satisfaction rate, perhaps there ought to be some means testing to qualify for these private sector programs. From a cost standpoint, perhaps would it be reasonable for government to encourage elderly Medicaid enrollees, in geographic areas where plans exist, to enroll in Medicaid Advantage programs.
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