Archive for the ‘Health Care Reform’ Category

PostHeaderIcon Donald Berwick – Medicare Chief Resigned

Due to political pressure Donald Berwick resigned from his post as a Center for Medicare and Medicaid (CMS) administrator.

Dr. Berwick was appointed by president Obama in 2010 during a congressional recess, effectively forcing his position to be reconfirmed by congress this year. Prior to this pending confirmation 42 Republican senators signed a letter pledging to block his confirmation, effectively ending any chance of him serving beyond 2011.

What is so wrong with Dr. Berwick? What did he do to make many republicans angry?

He praised the UK National Health Services when he was visiting the UK. He also made some comments that can be interpreted as rationing. Honestly I don’t know too much about the UK National Health Services. All I know that everyone gets basic medical care free of charge, and they have problems with waiting for advanced imaging and surgeries. I would say the first part is admirable, the second part no so much.

I am still puzzled the anger of congress regarding rationing. If you think about it healthcare rationing is a way of life in the US. We just call it Utilization Management in the case of insurance, Local Policy Determination in the case of Medicare. When we are considering Medicaid we simply have no doctors whom are willing to treat patients for the assigned cost. Our last group is the uninsureds, whom can’t afford insurance, therefore can’t afford healthcare. Presently in the US we are rationing by ability to pay.

I am a believer that Dr. Berwick would have made a difference in our health care system if congress gave him a chance to continiue on the path he already started.

Dr. Berwick came to CMS following enactment of the controversial Patient Protection and Affordable Care Act (PPACA). In his 18-month tenure, Dr. Berwick supervised the rollout of essential health reform regulations that promised to reshape both the private insurance market and the Medicare program. CMS drafted rules for the new health insurance marketplaces, called exchanges, where Americans will be able to compare and buy health insurance plans in 2014. He is responsible for putting in place a pilot program to move Medicare away from paying doctors based on volume of services to quality of care.

Dr Berwick advocates patient centered care; hospital care that works with the needs of the patient; not the medical staff. He doesn’t want a patient or himself “to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep.”

I am personally sad to see him go. His medical values and believes would significantly improved our overall health care.

PostHeaderIcon The High Cost of Poor Care

Nearly 388,000 nursing home residents’ deaths each year are attributed to infections. Approximately 25% of all hospitalizations of nursing home residents are caused by infections; the costs range from $673 million to $2 billion.

The FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. At the same time CMS reports that, nationwide, 39.4% of nursing home residents who had cognitive impairments and behavior problems but no diagnosis of psychosis or related conditions received antipsychotic drugs.

Use of chemical restraints is a major cause of nursing home falls, including hip fractures, which are estimated to cost $746.5 million.

Lack of toileting leads to urinary incontinence, in turn it leads to skin irritation, decubitus ulcers, urinary tract infections, and additional nursing home admission and hospitalization. Estimated cost $3.26 billion annually.

Poor hydration, along with poor nutrition, decreased mobility and cleanliness leads to pressure ulcers. Treatment costs are estimated to range between $1.2 and $12 billion.

Hospitalization of a dehydrated nursing home resident costs, on average, more than $18,000. Dehydration is often avoidable if residents are given more fluids. Insufficient staffing leads to less fluid intake by residents.

Three-quarters of all nursing home residents have at least one fall each year, and a quarter of the falls require medical attention. Twenty to thirty percent of the falls are preventable. Falls cost, on average, $19,440 and hip fractures, more than $35,000.

Poor care leads to excess hospitalizations, costing nearly $1 million.

Present plans by our government to fix nursing home expenses for Medicare and Medicaid patients:

Medicare-Medicaid Coordinating Office (MMCO) was established under the authority of the PPACA to address cost of care and improve access.

There are three initiatives in the works.

1. Capitated model – basically contracting with insurance companies to create a blended Medicare-Medicaid rate

2. Fee-for-service model- this model supposed to share savings from Medicare hospitalization reduction due to better quality care in dual eligible nursing home residents within each state.

3. Improved Care Quality for Nursing Facility Residents – this project plans to contract with independent entities to implement better practices to prevent conditions that leads to hospitalizations. The project aims to target 150 Skilled Nursing Facilities with high rate of hospitalizations. (Will observation be counted into these admissions?)

The real fix is simply having more nurses and nurse aides to provide better care.

PostHeaderIcon Pre existing conditions

Insurance language defines pre existing condition as a symptom, illness or health condition that was known and existed prior to the writing and signing an insurance contract. Health or life insurance policies will typically not cover pre-existing conditions until a specified period of time has elapsed. Depending on federal and state laws pre-existing conditions may not be covered at all.

The Health Insurance Portability and Accountability Act (HIPAA) provide some protection for people in transition, although it doesn’t go far enough.  The HIPAA law allows a 63 day gap between health insurance coverage.  Once the person is without medical insurance over 63 days, they are vulnerable to insurance company searches in to their medical records.

Unfortunately there are a lot of people affected by this unreasonable rule created by the insurance companies.
In a recent case a young woman was hospitalized and one of her old diagnosis was listed on her medical bill.  This code was put on to represent her historical medical condition and had nothing to do with her recent hospitalization.  Unfortunately, this simple coding oversight prompted her insurance company to deny her hospital and all other relevant medical bills.  The denial brought on disbelief, then frustration and anxiety.  Finally a well drafted letter from the treating physician clarified this new medical care need and all her claims got paid.

Another case involves a man who has been out of work for about two years.  His COBRA had run out and he couldn’t afford medical insurance, therefore his coverage gap went over the 63 day threshold.  One month later he finally got a job with medical insurance. Three month later he found himself in emergency surgery.  Unfortunately the surgery was similar in many ways to his previous condition and anatomical location.  Fortunately, the sudden illness was a newly manifested condition; therefore his insurance cannot deny his medical claim.  With that said it does not mean they don’t try.  Several request letters were sent to the patient.  These letters are originating from a third party company and asking for his signature to give authorization to request all his medical records.  Fortunately he was referred to us at MedBillsAssist, before he had signed any authorizations.  Our first action with the client was to acknowledge the request letters, but did not authorized access to his medical record.  It is always a bad idea to permit third party company to start looking through medical documentations.  The reason is simple:  records aren’t always correct. Hospital and physician records are handled by many and the process is error prone.  It is a very good idea for patient to request medical records and review them for accuracy.   According to HIPPA regulations, a patient can request their own medical records simply by signing and dating a request to release.       Once a person satisfied that the documentation is what he/she understands to be true, then it can be forwarded to the third party for review.  If there is an error the patient has a legal right to request correction of that error.  A simple letter to the hospital or physician to modify the medical record should be sufficient.

The Patient Protection and Affordability Care Act prohibited insurers to deny claims for children, except in grandfathered individual health insurance plans, based on pre-existing condition starting last fall.  The same law will apply to adults in 2014; provided the law will not be modified.

PostHeaderIcon Health Reform – Implementation 2011

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

  • Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

  • Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

  • Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

  • Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

  • Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

  • Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

Read the rest of this entry »

PostHeaderIcon Healthcare Reform Update

Many health care reform provisions went into effect on September 23, but as with any new law some will start right away, and others will slowly be implemented over time.

Small business tax credits for companies with fewer than 25 employees are now in effect. Provisions to rescind policies are banned. People now are afforded federally protected appeals rights.
Some provisions are not welcome by the insurance industry and are being challenged in their own way. For example, insurers are now prohibited from denying coverage for children with pre-existing medical conditions. Insurance companies have responded by eliminating children’s policies in several states.
The ugly duckling, known as the medical loss ratio, is being legislated at 80% for small groups and 85% for large groups with a mandated rebate if the insurer fails to meet these ratios. Insurance companies have responded by reclassifying certain expenses as medical services.
Although other provisions are already in effect, such as dependent coverage for adult children up to age 26 for all policies, and requiring qualified health plans to provide minimum coverage for certain preventive services without cost sharing, these will only start when policies are renewed. In many instances, this will be in January 2011.
Interstate insurance exchange programs should already be in place, but they are running far behind schedule. The federal government does not know how to run them and state programs are so different from each other that most states have decided not to run their own.

Most states estimate serious financial shortfalls in this program; therefore they are hesitant to get it started.

Medicare changes are taking effect as well, such as cuts in all hospital payment rates, payment reduction to Medicare Advantage plans and a significant start in eliminating the prescription coverage gap.

PostHeaderIcon Health Care Reform

The Patient Protection and Affordable Care Act was signed into law last week by the President. According to estimates it will afford coverage for an additional 31 million legal US residents; an estimated 24 million remains uninsured.

The most significant changes to the current health care system are:

  1. Elimination of pre-existing conditions limitations.
  2. Elimination of calendar-year and lifetime maximums.
  3. Establishment of community rating with variation for age and geography.
  4. Permitting young adults to remain on their parent insurance plan until age 26

The Congressional Budget Office (COB) estimates that the coverage provisions in the bill will cost 848 billion over ten years. Most of the major provisions will not take effect until January 1, 2014. Therefore, the current COB estimate uses 10 years of revenue to cover 6 years of coverage. In contrast, Republican staff on the Senate Budget Committee estimates that the total spending in the bill for 10 years will exceed 2.5 trillion.

The bill creates an estimated 150 new government entities to the teeming bureaucracy and countless new additions to the already overly complex tax codes.

More regulations will force everyone involved to spend more money on administration, driving the ultimate cost of health care even higher.

Large business entities and insurance companies will pay higher taxes, and those not providing insurance will be penalized. Small businesses, with less than 25 employees, will receive subsidies.

Extended coverage will be achieved by extending Medicaid for lower income individuals and families, providing tax credits for people above the Medicaid income threshold and by interstate insurance exchanges for the presently uninsured.

The law is promising protection from exorbitant out of pocket costs in the form of yearly caps on co-payments and co-insurance charges. However, it does not address the small print, such as usual and customary rates and non-covered (medically needed, but excluded from policy coverage) charges. It appear that the burden is entirely left on the insurance companies, but in reality the public will remain unprotected from overcharges and non-covered expenses. We are still at the mercy of deals made by insurance companies and large hospitals.

Physicians, the backbone of health care, are still affected in several ways. They are still forced to take contract of adhesions, limiting their ability to negotiate fees with insurance companies. They are still waiting for the permanent fix to the faulty Medicare formula, that was removed from the bill and replaced with a temporary fix. Tort reform, a major player in health care cost, hasn’t been addressed.

This legislation missed the mark of real reform. It only added several layers to an already fragmented system. It missed the opportunity to address real cost control, both by insurers and medical providers.

Regulatory authority between the federal and state governments is still divided and will be clarified via regulations in the coming years.

Regardless of what we think about this bill, it has been passed. Now it is time to move forward and make it work, hopefully, for all Americans.

PostHeaderIcon Temporary fix to what seem like permanent problem


President Obama signed H.R.4691 – Temporary Extension Act of 2010 into law on 3/2/10

Time and money spent on administering health care is a necessary cost, but when this goes to the extreme, one must take note and wonder. Medicare, our largest “insurance” in the nation is closely controlled by government rules and regulations. One would say that the government, that wants to lower health care cost, would not create additional burden for providers and insurance companies in the form of, well, additional administrative cost.

The freshly signed H.R. 4691 is a prime example of administrative government squander. This bill allows two Medicare fixes on the temporary basis; patches a 21.5% physicians pay cut, and extends the physical therapy exception process.

Pay rates for doctor services are calculated by a formula based on the GDP, the number of beneficiaries, and other variables. It has been in place for 13 years.  Due to drop in the GDP and increase in the number of beneficiaries, the doctors were to receive a 21.5% pay cut on January 1st. This law allows a temporary override, leaving doctors pay at present level until March 31, 2010.  

Physical therapy enables patients to regain their mobility after surgery, injury, illness, etc. Caps on therapy services were put in place to control Medicare expenses. The cap exception process allows some individuals to continue therapy, above the annual limit, when suffering from additional complex medical conditions.  For example, Parkinson’s disease qualifies a Medicare beneficiary to receive more physical therapy services under the exception rule.

A physical therapy service exception has expired on December 31, 2009. Once a beneficiary reaches their limit, they are notified and must pay out of pocket for additional services.  The new extension allows payment and now, claims need to be resubmitted, or reprocessed.

Starting on April first the same, insane, process will begin.  Medicare intermediaries will hold claims and wait for the government to fix payment rates.

The administrative nightmare is going on behind the scenes.  The Medicare contractors (actual insurance companies) are holding claims for two weeks, and then release them, applying rates that is in effect at that time. Most certainly these insurance companies had and will have administrative cost increase related to the frequently changing regulations that need to be added to their systems. Would someone remind the government that they suppose to lower the administrative cost instead of increasing it?

PostHeaderIcon H.R 3590 Patient Protection and Affordable Care Act….

Many important parts of the health care reform has been discussed in length by the media. In this media frenzy, among many other things, we learned about special interest, state specific spending and pork in the bill. In the mist of political badgering there was one important provision in this senate version of the bill, that I am sure everyone would like to see.
The amendment states that Congress should have exactly the same medical coverage that they impose on the citizens of the USA. Here’s a quote from the H. R. 3590 Patient Protection and Affordable Care Act:


(i) REQUIREMENT.—Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are:

(I) created under this Act
(II) offered through an Exchange established under this Act

This amendment had been added by Republican Senator Tom Coburn, the Senate health committee voted 12-11 in favor of adding the provision, who used Congressman John Fleming’s two pages House Resolution 615 to add this amendment to the bill. Interestingly, both Coburn and Fleming are physicians who probably know a thing or two about health care.

The proposed Act is the Senate’s version and will be voted on by the House. As such, The House may remove this amendment from the final bill; however, you have to applaud the effort of Coburn and Fleming just to put this addition into the bill.

PostHeaderIcon The House Approved a Revised Version of Healthcare Reform

  The House of Representatives approved a revised version of the healthcare bill last night.  The 219 Democrats and 1 Republican call it a bill defining social policy achievement.

I wonder how many of these Democrats will be making this same statement four years later.

Voting no for this bill are 39 Democrats and 176 Republicans.  Perhaps the House of Representatives is thinking the same way as Kevin Brady (R-TX) who was quoted in the New York Times saying “This government takeover has got a long way to go before it gets to the President’s desk, and I’ll continue to fight it tooth and nail at every turn. Health care is too important to get it wrong.”

 I also wonder if George Miller (D-CA), the chief architect of this bill, will call it revolutionary in 10 years and 1.1 trillion dollars later.

Republican consensus is that this bill is too costly and will end up hurting our fragile economy even further.

This bill is a wrecking ball to the entire economy,” said Representative Jack Kingston (R-GA). “We need targeted specific reforms to help people who have fallen through the health care cracks.”

The House bill is 1,990 pages long and requires most Americans to obtain health insurance or face penalties. Most employers will have to provide insurance coverage or pay an 8 percent tax penalty. According to Virginia Foxx (R-NC), “More taxes, more spending and more government is not the plan for reform the people support.” Other Democrats argue that this bill will bring the health care cost under control.

It may be naive to ask, but why aren’t the 15 million government employees joining the public option as their source of insurance?  This would ensure firsthand experience for Congress, the actual creators of the plan.

PostHeaderIcon Healthcare reform update – part two

The Senate Finance Committee approved their version of the healthcare bill. This proposal eliminated the public option and left states to fend for the uninsured and formerly untaxed medical coverages and insurances are now ridden with taxes — insurance policies that cost over $8,000 annually will herein be taxed.  Individuals without insurance will be penalized.
The new proposal contains long needed reforms, such as elimination of any pre-existing conditions penalties as well as the removal of lifetime caps.  Other measures, such as elimination of co-pays and deductibles, could be beneficial but we all need to remember that added benefits carry added cost.  

Both houses are working to combine five healthcare proposals to come up with two competing bills. Somewhere along the line, Congress lost track of the need to devise a bill that is best suited for this nation as a whole. The goal now is to formulate a bill that will pass with enough votes.

Healthcare reform is too important just to pass any bill. The erroneous bill will do more harm than good.