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Tag: Health Care Reform

Does Obamacare Limit Profits for Health Insurance Companies in Your State?

One of the provisions in the Patient Protection and Affordable Care Act (a.k.a ACA, a.k.a. Health Reform, a.k.a. Obamacare) is that it limits the profits of health insurance companies. The ACA imposes a minimum medical loss ratio (MLR) on all insurers. The MLR is the amount of money spent on covered person medical care divided by the total revenue received through premiums. There is some debate of what constitutes ‘medical care’ (e.g., do investments in electronic health records count as medical care?), but insurer profits certainly are non-medical.

The ACA requires health insurers in the individual and small group market to spend 80 percent of their premiums (after subtracting taxes and regulatory fees) on medical costs. The corresponding figure for large groups is 85 percent. According to a recent Kaiser tracking poll, 60 percent of the public views the MLR concept favorably, although only 38 percent was aware that the provision is in the ACA. Insurance brokers may be getting squeezed for insurers to meet this amount.

Even though the MLR is a national law, it may not apply in your state. Continue reading…

Bring Back the Public Option

The way health care is administered in the United States is unsustainable and in need of fundamental reengineering — right? During the 2008 presidential race, the country appeared to be in agreement on this point. But that all changed somewhere, somewhere after the election of a dark-skinned new president with a foreign-sounding name whom even proud Medicare card-carrying Americans were viscerally driven to deride as a socialist.

This was recently reported in The Hill: “The six largest investor-owned health insurance companies saw a 22 percent increase in combined net income in the third quarter, putting them on pace to break profit records for 2010.” The president was castigated by loud little crowds around the country for championing the overwhelmingly popular idea of a publicly funded, public health insurance alternative to challenge the partly publicly funded, private health insurance companies’ assertion that they simply cannot provide their services any cheaper. Rather than groundbreaking legislation, what we got was the president being caricatured on national television, in effigy, as The Joker — and health insurance executives laughed all the way to the bank.

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How Did My 2011 Predictions Turn Out?

Pretty well, actually.

As predicted last December, there was no big change to health care reform, doctors still didn’t have enough time with their patients, Microsoft (disclosure: Microsoft is a Best Doctors client) made moves to create a “Windows” for electronic health records, and “ACO” became the hot buzzword in health care.  Some state governments started major redesigns of their benefits programs, saving money in the same ways private sector employers do.  Meanwhile, more than ever, private sector employers are penalizing employees who don’t take care of themselves.

Misdiagnosis finally started to be recognized as a public health problem.  At Best Doctors we got a great deal of press coverage in 2011 on this (for a few examples, go herehereherehere and here).  I will sneak in a 2012 prediction and tell you that you will hear a lot more about this this year, and not just from us.

What did I get wrong?

Well, I said no major employer would drop their health benefits – and none did, so I didn’t really get this wrong.  But I was surprised to hear some very major employers quietly talking about their plans for dropping coverage in 2014.  It’s a bad idea – and I would have thought its badness would have been enough to keep it off the table.  For some employers, apparently not.

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2011’s Last Viral Lie About Health Reform

When so many good things have happened as the result of health care reform, I hate to end this year with a rebuttal to a viral lie about the Affordable Care Act. However, this one seems to come from a credible source but is so wrong that I can’t resist.

This is how the email reads:

“MUST LISTEN This needs to go viral. A brain surgeon called into the Mark Levin show. If you are over 70 years of age and you go to the ER and you are on government supported care, you will get comfort care instead of surgery. A government panel (a group of people that know absolutely nothing about medicine) will decide if you can have surgery and it has been decided that it will be denied if you are over 70. Patients will also be called “units” instead of “patients”. Sarah Palin was correct–DEATH PANELS!”

http://www.youtube.com/watch?v=0wsnHGI5K-E&feature=player_embedded

The video shows the radio host, Mark Levin, listening to this so-called brain surgeon call into his show. The surgeon claims that he has just been to a meeting of the American Association of Neurological Surgeons in Washington, D.C., where he learned something shocking! Obamacare will require only “comfort care” for people over 70. If you read the comments below the YouTube video, you are directed to the AANS site itself, where the Society blasts this person and his claim as a complete hoax. This disclaimer is on the AANS site under the “AANS news” subtitle:

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Scenario Planning in a Post-ACO and Post-ACA World


In a prior post, I provocatively suggested that providers, hospital boards and policymakers should hedge their bets and prepare for the possibility of a “post-ACO world.”  If the Group Practice Demo’s disappointing results are any guide, the likelihood of a happy ending for accountable care organizations is on numerical par with Congress’ approval rating. While I like the mutual “win-win” theoretical construct that underlies ACO gain sharing, it also recalls a life-lesson: want you want and what you get are usually two different things.

So, if the Feds have to eventually retreat on the non-success of ACOs, what will be left in its wake?  More on that in future posts.

And while the uncertainty surrounding ACOs isn’t bad enough, I have also been astonished by the battered Euro, the appearance of hospital-employed cardiologists and the absence of a Lady Gaga Christmas album.  Accordingly, I have learned my lesson and assume nothing.

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12 Common Medicare Scams

“To scam Medicare is not to give a damn for taxpayers. Money is money whether you earn it or steal it.”

– Anonymous

Christine Seivers of medicalbillingandcoding.org sent me the following list of common Medicare scams. I have edited and shortened her copy to fit my blog.

1. The Poser Scam

One common way to scam Medicare is to pose as a Medicare employee, a practitioner, or insurance representative. These fraudsters call, email, or send letters asking for personal information that includes bank, Social Security, and Medicare numbers.

2. The Healthcare Reform Scam

Healthcare reform is on the lips of everyone these days, and scammers are using it to cash in. Many adults don’t know what the new health care legislation actually entails. That’s just the way criminals want it. It makes many Americans easy targets for scams, like those that claim to sell “healthcare reform insurance” that purportedly protects seniors from any losses to their Medicare or any fines they make incur from not meeting guidelines.Continue reading…

Obamacare to the Rescue

I want to apologize to President Obama. But first, some background.

I found out three weeks ago I have cancer. I’m 49 years old, have been married for almost 20 years and have two kids. My husband has his own small computer business, and I run a small nonprofit in the San Fernando Valley. I am also an artist. Money is tight, and we don’t spend it frivolously. We’re just ordinary, middle-class people, making an honest living, raising great kids and participating in our community, the kids’ schools and church.

We’re good people, and we work hard. But we haven’t been able to afford health insurance for more than two years. And now I have third-stage breast cancer and am facing months of expensive treatment.

To understand how such a thing could happen to a family like ours, I need to take you back nine years to when my husband got laid off from the entertainment company where he’d worked for 10 years. Until then, we had been insured through his work, with a first-rate plan. After he got laid off, we got to keep that health insurance for 18 months through COBRA, by paying $1,300 a month, which was a huge burden on an unemployed father and his family.

By the time the COBRA ran out, my husband had decided to go into business for himself, so we had to purchase our own insurance. That was fine for a while. Every year his business grew. But insurance premiums were steadily rising too. More than once, we switched carriers for a lower rate, only to have them raise rates significantly after a few months.
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Justice Kagan Should Recuse Herself from Obamacare Case

This spring the U.S. Supreme Court will decide what may well be the case of the century — the constitutional challenge to Obamacare. But will the case be heard by eight or nine justices?

Before the health care law was even passed, the Department of Justice had been meeting to develop a strategy for defending the law from constitutional attack. Involved in this effort was none other than Elena Kagan, now the newest Obama appointee to the Supreme Court.

Federal law requires Supreme Court justices to recuse from a case if they had earlier “participated as counsel” in the case. Justice Kagan did just that when she was Obama’s solicitor general, but has never explained why she believes she is nevertheless justified in sitting on the case under this standard.

One simply can’t be the coach and referee in the same game. At best, knowing the playbook will color your judgment, and at worst, you’ll be on the lookout for chances to give your former team an advantage.

Here are the facts. It took two lawsuits to get “the most transparent administration in history” to release emails detailing Kagan’s involvement in the Obamacare defense. Those emails show that, in a highly unusual move, she ordered her staff to become involved in the defense before the law was even passed.

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Walmart Wants To Be Nation’s Biggest Primary Care Provider

Walmart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a confidential company document.

In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

The 14-page request asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.

Analysts said Walmart is likely positioning itself to boost store traffic – possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.

“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”

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Another Unpleasant Surprise from Obamacare

Whatever the disadvantages of the new health care law, Obamacare proponents appeared to be on solid ground when they said that it would extend affordable health insurance to millions of Americans.

No longer.

At the hearing of the health subcommittee of the House Committee on Oversight and Government Reform, Cornell University economics professor Richard Burkhauser showed that in 2014, millions of low-income Americans may be unable to get subsidized health insurance through the new health care exchanges.

It’s true that under Obamacare, firms with more than 49 workers have to offer affordable health insurance coverage to full-time employees or pay a penalty. But the coverage only has to be for an individual policy, not a family policy.

And what most people don’t know is that if a worker receives coverage for a single person from his employer, his family will not be able to get subsidized health insurance coverage under the exchange.

This is because, if one member of a family receives employer-sponsored health insurance, other members of the family cannot receive subsidized coverage under the exchange.

Other family members would have to purchase full-price health insurance, which would be prohibitively expensive for those at low incomes, those who are supposed to be protected.

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