Thursday, December 19, 2013

Healthy Resolutions for the New Year

While much of our nation's focus is on healthcare and insurance, the real root of the crisis is not getting enough attention. By and large, Americans are unhealthy. Most of us are overweight, overworked, overstressed and over-medicated.  That's the bad news. The good news is it's all fixable. It's just up to us, as individuals, to make the changes that will allow us to be healthier and lead more productive, happier lives. Yes, some medical issues and conditions are unfortunately hereditary and random facts of mortality; but a healthy lifestyle is absolutely, 100%, a choice. compiled a comprehensive Top Ten list of simple, healthy resolutions for the New Year. Here are their recommendations in short. I urge you to read the full article (link is below) and to share it with loved ones. Your lives depend on it.
  1. Lose weight
  2. Stay in touch with friends, family
  3. Quit smoking (Natural and Electronic)
  4. Save money
  5. Cut your stress (there are ways!)
  6. Volunteer
  7. Go back to school (or continue to educate your mind)
  8. Cut back on alcohol
  9. Get more sleep (Everyone wants just have to make it a priority. Remember the hours you keep is a CHOICE.)
  10. Travel,,20452233,00.html

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
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Wednesday, October 2, 2013

The Affordable Care Act Roll-Out

Demand for affordable health care was even greater than expected as millions of Americans overloaded the new health care exchanges the day they opened.  Federal officials said more than 2.8 million visitors between midnight and late afternoon yesterday contributed to long wait times for access to  the website they are running for 36 states.  Officials in New York state, which is running its own insurance site, said an unanticipated surge of visitors in the first hours left the marketplace only partially functional. California said its website fielded five million page views by 3 p.m. local time.  Despite the computer glitches and over capacity usage, there's no denying people all over the country are desperate for health insurance. That's the good news. The bad news is, can the government handle the operation?  

Operating the ACA is a massive undertaking. A lot of folks will look at all the initial problems and blame the government. They'll argue it proves once again how inefficient the government is and they should not be running what needs to remain exclusively a private business. The reality is that even if the private health insurance industry had reformed its system on its own, there would be similar problems with the initial roll-out. And what business runs 100% smoothly on its first day of operation?

The most important thing to take away from the last couple of days is that people do want better coverage AND to maintain some patience with the early implementation. Let's remember that we are only in an enrollment period for coverage that does not take effect until January 1, 2014.  There's no early sign up discount or added benefits either. So, you can take your time with looking into your options. You have until December 15 to enroll for a January 1,2014 effective date.   However, you can enroll as late as March 31, 2014 at which time the open enrollment period ends for this year..

And for those who still have questions on how exactly the new system works, here's a simple to follow animated guide to the Affordable Care Act from the Henry J. Kaiser Family Foundation.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 
A service provided by 
Claims Security of America

Tuesday, September 24, 2013

President Obama discusses Health Care with President Clinton at Clinton Global Inititiative 2013

Several years ago, Former President Clinton created a world philanthropy organization called The Clinton Global Initiative (CGI), which addresses and looks to assist with the world's most pressing issues. Every year, Clinton joins business leaders, political figures and philanthropists from around the world for a week in New York City. These meetings and speeches are streamed live on the internet. Today, a week out from the official Affordable Care Act roll-out, President Obama sat down with Clinton to discuss all the provisions of the new law, how it really works and how it's really being paid for. It's an intelligent, truthful, easy-to-follow conversation between two of the most highly educated American Presidents in history. Think what you want about each man's politics, but this exchange between the two is not a political one. Rather, it's an educated one. Here's the nearly hour long discussion, along with a brief introduction from a woman who knows both men, personally and professionally very well, Hillary Clinton.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 

A service provided by 
Claims Security of America

Thursday, September 19, 2013

Medicare Open Enrollment vs Affordable Care Act Open Enrollment

October 1, 2013 is the beginning date for the "Open Enrollment" in the newly created Health Care Exchanges and Marketplaces that have been enacted under the Affordable Care Act (ObamaCare).  

Our blog from August 21, "What Are These Exchanges All About?" details the 2013 Health Care Marketplace for all insured and non-insured looking for new coverage. However, even if you are happy with your existing coverage, you may find the new system to be even better and offer additional coverage at a reduced rate. Everyone should be exploring all their available options now.

Unrelated to the Affordable Care Act, the Medicare population also has the opportunity to change their Medicare coverage during the Annual fall Open Enrollment (AEP) beginning October 15 until December 7,  for a January 1, 2014 effective date.  This is an area we previously addressed in our October 26, 2012 blog. 

So, how do you know whether to choose traditional Medicare with a Medicare Supplement that offers a Prescription Drug Plan or choose a Medicare Advantage plan with Prescription drugs included?  Asking the following questions could be helpful in making the most appropriate decision.
  1. Were you satisfied with your Medicare coverage this past year?  If you were satisfied with your Medicare coverage, perhaps you need not make any changes.  If, on the other hand, you had problems with accessing providers in your Medicare Advantage Plan or wished you could go out of network to see any physician you wanted, then you may want to consider a change.
  2.  Do you anticipate high utilization of services next year? (tests, procedures, surgery, etc.)   If yes, then a change from your present Medicare Advantage Plan to traditional Medicare may be warranted.  The cumulative cost of co-pays and co-insurance under Medicare Advantage Plans can be greater than the costs of a Medicare supplement and stand alone Part D drug plan. 
  3. Did you enter the prescription drug doughnut hole?  If you are presently enrolled in a stand alone Part D plan you should do an analysis of your present drugs to see which Plan is best for you. Plan D programs are very drug specific and what worked for you this year may not be beneficial for you next year. Formularies, co-pays and premiums are different from Plan to Plan.
  4. Are you planning to move from your present residence next year?  A move to another location could be a problem if you are enrolled in an Advantage Plan. Out of network services are generally not available. Check with you Plan to see if they have a program in your new area if you still wish to be enrolled in an Advantage Plan, rather than the traditional Medicare program.
The official Medicare website,, gives excellent instructions on how to further best select the most appropriate Plan D option, evaluate Medicare plans and understand what Medicare covers. If you're enrolled in a Medicare Advantage and/or Part D Plan, you should  receive an Annual Notice of Change by September 30th.  This notice informs you if your current provider network and drug formula will change. These changes may help you decide whether or not to shop for alternate plans for the coming year.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 

A service provided by 
Claims Security of America

Thursday, September 5, 2013

Ex-President Bill Clinton addresses Affordable Care Act

On Wednesday, the former President took to the podium at his Presidential Library in Little Rock, Arkansas to defend and further explain the Afforable Care Act.  Obama refers to Clinton as the "great explainer" and knows many Americans still have their doubts about universal health care. Clinton effectively breaks down the good, the bad and most importantly, why it's time to stop bickering about something we all desperately need to work. Clinton argues, rather than debating on if it's going to work, let's all focus on how we can make it work better.  Here's a the speech in its entirety..

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate

Wednesday, August 21, 2013

What Are These Health Care Exchanges All About?

While many politicians in Congress continue to fight against ObamaCare and seek its removal, a key provision of the Affordable Care Act is already underway. A number of online marketplaces, or Health Care Exchanges, that allow patients to purchase health insurance coverage are being set up around the country on a state-by-state basis.  The exchange option for health insurance is not available to employees who choose to receive health care through their employer, those on Medicare or on Medicaid.  We will address the employer options and concerns in a future blog.

The new health care law requires all tax paying US citizens to have health insurance or pay a penalty.  Open enrollment begins on October 1, 2013, with coverage effective January 1, 2014. 
Individuals will be able to purchase insurance online through private companies who will compete for their business in a traditional marketplace. The Department of Health and Human Services (HHS) administers all the requirements for the exchanges and the health plans that can be sold on the exchange. This measure of quality control ensures that any plan bought on the exchange meets minimum requirements, further increasing consumer protection.

Individual states have the option to set up their own exchanges, partner with other states, or have the Federal Government build and run the exchange for them. According to the Commonwealth Fund, 18 states, as of July 2013, will implement their own health care exchanges; 8 states will use the Federal Government marketplace, but will manage the plan themselves, and 4 states will have state-federal partnerships, with the states conducting plan management and consumer assistance. The remaining states having federally facilitated marketplaces.  Here's a state-by-state map of who is doing what.   

Let's take a look at the basic components of these exchanges and how they might directly impact you.  

With all plans offered in the Exchanges, coverage cannot be denied because of a preexisting condition. In addition, the premiums for men and women cannot differ for the same benefit package. The essential benefits for all plans include: 
  •      Ambulatory/outpatient care   
  •      Emergency services
  •      Hospitalization
  •      Maternity and newborn care 
  •      Mental health and substance use disorders 
  •      Prescription drugs 
  •      Rehabilitative services and durable medical equipment
  •      Laboratory services 
  •      Preventive and wellness services and chronic disease management 
  •      Pediatric services
The benefit designs must conform to one of four tiers: Bronze, Silver, Gold and Platinum.  

These 4 plans will differ in costs and provider networks.

With the Bronze package, subscribers will pay more for their out of pocket costs than in the Platinum plan. In terms of deductibles, co-payments and other charges, the Bronze plan covers 60% of a patient's health costs, the Silver 70%, the Gold 80% and the Platinum 90%.  

Those with more limited and restrictive networks such as HMOs (Health Maintenance Organizations) will probably have lower premiums than those with less restrictive networks such as PPOs (Preferred Provider Organizations).

Depending on your income level, you may be eligible for financial subsidies toward purchasing health insurance. You qualify for this subsidy if your income is less than 400 percent of the federal poverty level, which is about $46,000 for an individual and $94,000 for a family of four in 2013. The subsidy represents the difference between the amount you're expected to contribute based on your income and the cost of the benchmark plan for someone your age in your state.   
For example, if your adjusted gross income is $70,650 for a family of four, you're expected to pay 9.5 percent of your income for the benchmark plan's premiums. According to Families USA if your family's premiums for the benchmark plan are $12,500, you'd be expected to pay $6,711 of the premium, and would get a tax credit worth about $5,790. The subsidy remains the same regardless of the level of plan you buy (Bronze, Silver etc).  Note, you can only get the subsidy if you purchase insurance through the exchange and not through your employer. The subsidy is sent directly to your insurance company and applied to your premium.  The Baltimore Sun explains how the subsidies work in more detail.

The premium costs will vary from state to state, and within the various benefits tiers. Anna Wilde Mathews of the Wall Street Journal summarized the diverse range of premiums for a healthy non-smoker 40 year old male in various states.  

"The least-expensive plan available to a 40-year-old nonsmoker in Richmond, Va., will be $193. 
In Ohio, carriers whose filings are available are proposing monthly premiums starting at $211 for a  40-year-old nonsmoker living in Columbus for a plan that covers 60% of costs. 
In Atlanta, Georgia, the least-expensive bid for such a plan is $212. 
In Olympia, Wash., a carrier has proposed charging $220.
In Hartford, Conn. early filings show such a plan could start at $242. 
....In Washington, D.C., the cheapest premium for a 40-year-old nonsmoker’s plan covering 60% of costs is $166, and...... in Nashville, Tenn., a plan is set to be available for $149 a month."

The differing state to state premiums above seem to be inconsistent with the notion of a Federal program requiring a set of minimum benefits.  Should there be consistent premiums throughout all states? Apparently not. In part, the state options may very well have been a political compromise.  One of the goals of the program that affects all states is to encourage competition amongst insurers in the free market economy. Contrary to many people's belief that the Affordable Care Act is socialized medicine; it is anything but that. This is not a single payor system.  It is like the Part D Medicare program - a Federal program with minimum benefits administered by private insurance companies. There are some variations and differences, but the Affordable Care Act is set up to encourage competition, which hopefully will ultimately be reflected in lower premiums. Premiums will continue to vary from state to state simply because the demographics vary in each state, and premiums are generally based on the expected utilization of the groups to be enrolled. 

While it is the intent of the exchanges to encourage more competition, we will not fully know the answer until after January 1, 2014.  And whether or not this change in the marketplace translates to more affordable insurance premiums and cheaper health care is something that will take some time to see.  Regardless, change is desperately needed in the health insurance industry. For now, The Affordable Care Act is a step in the right direction. 

Stay Positive. Stay Informed. Stay Healthy.
- The Patient's Advocate

Wednesday, June 26, 2013

Simple Tips for Paying Your Medical Bills

No one likes receiving bills, especially when they come from your doctor or hospital. Most of us just want to be done with the entire unpleasantness as quickly as possible, so we often just pay our "balance due" without even thinking about the charges. This behavior is understandable, but fraught with error.

Your "amount due" may be what you actually owe, but not necessarily what you alone should be responsible to pay. In other words, physicians and hospitals often bill the patient before the insurance covers their amount. Here's some tips to maybe save you money in the bill paying process.
  • Never pay before the insurance pays and you have an explanation of benefits (EOB). The EOB should tell you the charges, amount approved by the insurance company, the amount paid and how much you owe.  Don't worry about your doctor getting angry if you don't pay the bill as soon as it is received. They're not exactly hurting financially.
  • Always ask your physician if they file to insurance. It's often their responsibility to file the necessary paperwork in advance of receiving payment if they accept the assignment from the insurance company. By accepting the assignment, the doctor agrees to accept, as payment in full, what the insurance company approves.  He/she must write-off the difference between the approved amount and the charged amount.
  • Doctors may charge you a co-insurance payment upfront upon all visits. If your doctor is in the network, which usually means he accepts assignment, ask that you get billed for the co-pay after insurance has been filed and reimbursement received.  A common occurrence is that you may be asked to pay your co-insurance (20%) based on the full charge, as opposed to the approved amount. If you are paying a co-insurance at the time of your visit, make certain that it is based on the approved amount.  If not, you will overpay and may not get a refund if you and/or the doctor's office do not realize the error.
  • Just because you're being charged a number that your insurance does not fully approve does not necessarily mean you're responsible for the difference. Sometimes, providers are willing to accept the insurance's allowed amount even if they don't accept the assignment. It's in your best interest to at least ask if they're willing to make the adjustment.
  • Anytime an insurance denies coverage or a charge, question it.  They may turn out to be correct, but just as often, the provider miscoded the claim or wrote the wrong diagnosis for insurance purposes.
  • After you finally pay a bill, make sure you document it in terms of amount paid and method of payment (check, credit card, etc.).  This is extremely important in the event you receive a duplicate bill later.
Following these tips will not be the cure for all your ills, but they will certainly protect your financial health.

Stay informed. Stay positive. Stay healthy.
- The Patient's Advocate

Monday, April 1, 2013

How to Choose the Right Doctor

So much attention today is paid to the rising costs of our medical care, premiums and what our insurance does and does not cover. Often over looked in the process is who is the person delivering the care.  Under what criteria should we select a physician?

Sometimes, we're restricted in who we can visit based upon our insurance limitations. However, when we do have flexibility, the majority of patients are still ill equipped to objectively choose the best physician available. Most decisions result from emotional and highly subjective considerations. Does he have a good personality?  We think, if my friend likes him, he's probably a good physician. Or, if he's been in practice for a long time, so he must be good, because the more experienced a doctor has the better he is. Perhaps he was simply recommended by another physician. While some of these may be valid reasons for physician selection, they are not based on the criteria that relate to overall quality of care issues.

Here's a few specific ways to begin the search for the doctor who best meets your needs.  
  • Check the physician's basic credentials.  This provides a baseline for the type of training a physician received.  Many states offer physician profiling websites which detail the physician's education, training and specialty board certifications.  Or try DocFinder for its easy to use search engine. DocFinder remains the only database that combines all licensing jurisdictions by state licensing boards and remains free of charge to the public. In addition to physician profile information from states that have passed physician profile laws, the website contains the licensing background and disciplinary information of physicians and other health care practitioners. The American Board of Medical Specialties allows you to check Board Certification on their site, as well as any disciplinary action taken against the physician, including malpractice/liability issues.
  • Check field specific expertise or procedures.  This is important especially when selecting a surgeon or sub-specialist like an oncologist.  It is entirely appropriate to ask the physician how many procedures, such as the one for which you are seeking help, he has performed.  The phrase "more is better" is probably appropriate in this case.  An orthopedic surgeon who has performed 1000 hip replacements is probably better than the one who has done 100.  However, there is a caveat.  Surgeons with less experience may have been more recently trained in newer and better techniques.  They may be using more state of the art surgical procedures.  Older surgeons, for example, may not have been trained or feel comfortable in minimally invasive robotic surgery. Younger surgeons are trained in these techniques and may not be as proficient in the traditional open surgical procedures.  A recent Consumer Reports story said "When deciding on a surgeon, remember that caseload may be more important than a surgeon's age. An analysis of Medicare data for nearly 461,000 patients found that while surgeons over age 60 with low surgical volumes had higher patient mortality rates on some procedures, those who continued to maintain high surgical caseloads had comparable outcome with surgeons ages 41 to 50."
  • Another aspect of physician selection relates to seeking a second opinion.  You should always seek a second opinion when surgery is recommended or a particular treatment or procedure is proposed, such as cancer treatment.  Mistakes are often made in diagnosis which leads to inappropriate treatment.  It's invaluable to hear another opinion. A recent Wall Street Journal article by Holly Finn talks about second opinions:  A 2010 Gallup poll found that 70% of Americans are so respectful of their doctor's advice that they never get a second opinion or do additional research. We apply more scrutiny to choosing bluejeans, buying flat-screen TVs or ordering lunch. A good doctor will welcome you seeking a second opinion from another physician.  You cannot be concerned about hurting your doctor's feelings by going for a second opinion.  If you are close to a major teaching hospital medical center, take advantage of your access to the very best in your area. If you cannot seek out a teaching hospital environment, then the experience and credentialing criteria suggested above should be utilized to select a second opinion.  Always remember, if your second opinion physician is different from your first, then you should seek a third opinion.  You should have at least two opinions that are the same or similar to make an educated decision.
  • The Human element.  No matter how skilled your doctor may appear if you do not feel comfortable talking to him or relating, this could lead to unexpected stress and frustrating communication down the road. Do not take for granted the importance of a rapport with your physician.  
  • Insurance participation. You should always ask if the physician participates with your insurance plan.  This can have significant cost implications.  If he or she participates/accepts assignment, then the physician agrees to accept as payment in full the amount approved by the insurance company.  On the other hand, if he is out of network, and therefore does not accept the assignment, then he can charge you the difference between the approved amount and the approved amount.  In the case of Medicare, a doctor who does not accept Medicare Assignment can only charge 15% above the Medicare approved amount. Often times you can negotiate a preset reduced percentage ahead of time with the physician if they're aware your insurance will not cover the treatment.
  • Hospital affiliation.  It may be helpful to verify the hospital(s) in which the physician has admitting privileges.  Hospital services and and quality vary from one to the other.  You may want to inquire about re-admission rates for the patients, infection rates, mortality rates by diagnosis or admission type.  Many state health departments require hospitals to report on various infection rates. Centers for Medicare and Medicaid Services has published the infection rates on its Hospital Compare website, where the government already publishes data about patient satisfaction and some other types of medical errors in order to help consumers choose quality hospitals.  Not all hospitals are created equal.  

While the above recommendation are not an all inclusive list, at least you have some additional guidance to now select a doctor with more confidence and objectivity.

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
Any additional questions or concerns please call:
1-800-400-4066 and ask for Harvey.

Thursday, March 7, 2013

Escape Fire: The Fight to Rescue American Healthcare

A TV program note worth watching or setting your DVR for is CNN's premiere of the award-winning documentary, Escape Fire: The Fight to Rescue American Healthcare on Sunday March 10 at 8pm and again at 11pm ET.  While I have yet to personally see the film, it looks like it discusses many of the important issues. 
The film premiered at the 2012 Sundance Film Festival and received honors at the 2012 Silverdocs, Full Frame, and other prominent festivals.  The two-hour feature-length film was produced and directed by Matthew Heineman and Academy Award-nominee Susan Froemke and distributed by Roadside Attractions and Lionsgate. 
The film reveals flaws in the notion that the healthcare delivered via America’s patchwork of facilities, practitioners, and insurers offers good value for its outcomes.  Through the real-life experiences of physicians and patients, Escape Fire shows the tremendous pressures providers feel to reduce costs and limit patient interaction time – and the frustrations of patients struggling with preventable conditions that are often created or exacerbated by insufficient or inappropriate care.
Americans spend nearly twice as much on healthcare as any other country on Earth, but lag behind nearly every industrialized nation in life expectancy – ranking number 50 out of more than 220 nations around the world in the 2011 CIA World Factbook.  In the film, former Administrator for the U.S. Centers for Medicare and Medicaid Services Dr. Don Berwick, and the former director of communications for insurance giant CIGNA Wendell Potter, explain this as partly due to the impact of for-profit interests that guide an uncoordinated care system that focuses more on disease management than disease prevention.
“CNN Films is very pleased to bring this documentary to television,” said Jeff Zucker, president of CNN Worldwide.  “The physical health of our nation and the cost of healthcare, impact every current fiscal challenge we face.  This compelling film gives us an explanation of some of the factors that have contributed to our broken system and explains why we urgently need to fix it.”
Filmmaker Heineman said, “CNN is the perfect place to release Escape Fire to spark an honest and important dialogue about the future of healthcare.”
Viewers meet a war-injured veteran seeking to wean himself from dozens of medications for his pain and post-traumatic stress disorder symptoms with acupuncture, meditation, and other more holistic remedies, a short-order cook who accesses his local hospital emergency services since he does not have a primary care physician, and a mother with heart disease, who learns less expensive, less invasive procedures may have helped her to avoid her multiple surgeries.
The film also offers innovative healthcare solutions from leaders in the public and private sector, including noted holistic health experts Dr. Andrew Weil and Dr. Dean Ornish, Safeway grocery chain CEO Steve Burd, medical journalist Shannon Brownlee, Cleveland Clinic cardiovascular chairman Dr. Steven Nissen, and Dr. Berwick.  They describe this moral hazard for physicians – predominantly fee-for-service health care payment models incentivize medical interventions yielding higher profits and spend less time counseling patients how to curb or avoid illness related to behaviors that cause conditions like obesity and diabetes in the first place.
CNN chief medical correspondent Dr. Sanjay Gupta will moderate a 30-minute discussion following the exclusive premiere broadcast of Escape Fire, focused on how Americans can cut through the red tape to save money and increase their access to healthcare.
Here is the trailer for it:


Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate

Tuesday, February 26, 2013

Why Medical Bills Are America's Real Killer

The fastest spreading disease in America cannot be cured with a flu shot or prescription drug. It's far more complicated.  The red tape and sticker shock associated with our ever increasing medical bills is America's real killer. In the most recent issue of Time Magazine, Steven Brill, sets forth, in riveting detail, the problems faced by patients today when it comes to paying their medical bills.

Many of us can relate to these horror stories that include overcharges, denied claims, or unnecessary charges.  Whether we didn't have appropriate and adequate insurance coverage in the first place or just thought there was nothing we could do about exorbitant hospital fees, we all struggle to pay the bottom line. On top of our personal issues we fail to reconcile, insurance companies often refuse to or simply inaccurately make the proper adjustments to their reimbursement, even when they are legally contracted to do so.

While the Affordable Care Act (ObamaCare) will provide access to health care for more than 30 million people without health insurance, through the health care exchanges currently being set up for 2014 implementation, it will probably not significantly lower the costs of healthcare. As Brill points out in his article, the main reason for this is that the medical marketplace does not behave in the same manner as the marketplace for all other goods and services. When I go to buy a car, I know, with some preparation in advance, what the cost of the car will be.  If I don't like the offer the salesman makes, I am free to shop at another car dealer to try to get a better price.  This never happens in the health care arena.  Rarely do we know in advance how much it will cost, nor do we shop for a better deal. We may shop for better care...but rarely is price a factor. And the industry knows this and takes full advantage with its pricing structure. We have very little, if any, negotiating power with hospitals and other healthcare providers. Only Medicare has the power to negotiate with hospitals and other providers, while private insurance companies do not.

Forget about actual medical care. Let's just look at the paperwork in the current system. Brill points out that the Medicare program costs $3.80 to process a claim compared to $30 per claim for Aetna. With this kind of disparity it's hard to argue that further privatizing medical care makes any sense or...cents at all. The misidentified truth is, when it comes to health care, government intervention actually keeps costs down.

Mr. Brill identifies the reason hospitals, and the rest of the industry, have been able to get away with this kind of pricing to date. Hospital charges do not reflect the reality of the actual costs for services rendered.  How these costs derived by the "Charge Master" is a well guarded secret to patients. While very few of us will ever pay these  intentionally over inflated, unrealistic charges; they do serve as a ceiling from which hospitals may be willing to negotiate lower fees. However, the problem lies when negotiating an adjusted hospital bill for clients, we usually start at the Medicare reimbursement level and work our way up, rather than begin at the upper level of the Charge Master fees, and work down.  A reduction by the hospital from the full billed charges as they appear on the Charge Master, is usually still much higher than the adjustment made by an increase in the Medicare allowable amount.

The ability to control health care costs is a function of two main variables: price and utilization.  If we can impact just one of these, we will bring about change.

Unfortunately, the recent trend toward integrative delivery systems, whereby hospitals are buying up medical practices will have a significant negative impact on the cost equation and the ability to reverse the increasing  medical expense trend.  In the days when individual practices dominated, insurance companies would be able to exercise leverage in negotiating reimbursement.  According to Southwind, a Nashville, Tenn. based consulting group, with hospitals now employing 1 in 4 physician specialists and 40% of primary care physicians, compared to 1 in 20 specialists and less than 20% of primary care physicians in 2000, hospitals are becoming the dominant player. While more and more physicians continue to trade off their independence for security, in terms of guaranteed salaries and bonuses based on productivity, hospitals increase their negotiating leverage with insurance companies because of the significant numbers of patients (insurance subscribers) represented through their physician owned practices.  Insurance companies find themselves virtually defenseless in setting reimbursement, and ultimately, affecting price breaks for subscribers.

Hospitals will contend that their integrative approach to the delivery system will lower costs. But, as long as their physician owned practices are allowed to continue the "fee for service" model in terms of reimbursement, it matters little that the physicians are paid a salary. The only effective solution is to tie reimbursement to outcomes that measure quality, and not solely by the number of visits or tests performed.  In addition, the trend of buying up private practices by hospitals only adds another layer of fees, often labeled as a "facility fee" that the hospital now tacks on for its "consolidation."

In its March report to Congress, Medcap, a government agency that analyzes Medicare policy, found that the cost for a basic doctor visit nearly doubled once a practice was purchased by a hospital group. The reports claims that last year, a 15-minute visit to a doctor in private practice cost $69, including the $14 patient co-pay.  That same visit to a hospital-employed physician cost $124. The patient portion rose to $25. According to Medcap, at that rate, Medicare spending for doctors visits alone would increase by $2 billion a year. Analysts at Florida Blue, the state's largest provider of health insurance, found similar numbers when they looked at data from cardiologists who practiced in Orange, Osceola and Seminole counties. During the past two years, they discovered that overall costs from hospital-employed cardiologists were 20 percent higher than for cardiologists not employed by hospitals.

As long as Hospitals and Doctors are allowed to operate as a typical American business seeking dominant market share and revenue, the quality of care and the cost to receive said care will never add up to numbers that benefit the ones who need it most. Despite all the new regulations in place, if the government does not step in to further reform the way the health industry charges its subscribers, even fewer Americans will be able to afford the care they so desperately need. While the owners and operators of the health care industry manage their business like every other business in a free market system, the users of this system do not behave in the same way as other consumers in other industries. It's imperative for the politicians and all citizens to understand the difference.

Setting realistic quality and cost control standards that improve the power to negotiate fees and services is imperative, if we're ever going to stop what's killing our healthcare system. Greed and profiteering may be good for business, but it's very bad for the individual's health and personal fortune. By excluding the delivery of quality outcomes and managed price ceilings, health care costs will continue to soar.  Left unchecked and unregulated, hospitals and physician groups will only continue to care about the business of growing large  provider networks at the expense of quality, affordable patient care.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate

Wednesday, February 13, 2013

Caregivers & The Family and Medical Leave Act

At some point in our lives most of us will need to provide care for a parent or family member. Whether or not we're able to do this on our own or with the aid of a professional, medical assistance for a loved one is an issue none of us welcome but, know one day, will be a necessary inevitability. The question is, how do we best prepare for it, and then manage it, when the time comes?

2013 marks the 20th anniversary of the passage of The Family and Medical Leave Act, the very first piece of legislation under the Clinton Administration. This landmark legislation guaranteed caregivers up to 12 weeks to spend more time with their loved ones in times of emotional and physical distress. The  graphic chart below shows the dramatic shift from 1992, the year before the enacted legislation, compared to twenty years later. 

President Clinton revisited his legislation in an op-ed piece for  Here it is, in its entirety.

The late 20th century will be remembered for the onset of dramatic economic, social, environmental and political changes which continue to challenge us at home and abroad. Though our increasingly interdependent global economy allowed people across the world to trade, invest, communicate, debate, and make common cause at a level never before imaginable, the news was not all good. 
In the U.S., middle class incomes began to stagnate in the 1980s, child poverty was rising, as were welfare rolls, teen pregnancy, crime rates, and income inequality. More and more of the nation’s growth was benefiting those already doing well. 
By 1993, the patterns of family life had been changing for decades. Between 1965 and 1992, the percentage of mothers with children working outside the home had grown from 35 to 67 percent, giving women new opportunities and allowing middle class families that once prospered on a single paycheck to maintain their lifestyles with two incomes. Meanwhile, single parent households had become much more common in America, growing from 16 to 27 percent of families between 1975 and 1992. Many children in these homes were living in poverty even when their parents, usually mothers, worked. 
These stark developments caused many to question whether, in spite of our progress toward gender and racial equality, the American Dream could survive the turmoil. Therefore, the question most Americans wanted those of us running for the White House in 1992 to answer were: how can we restore the American Dream for those who work hard and play by the rules? How can we empower the poor to work their way into the middle class? How can hard-pressed parents do a good job at work and at home with their kids? 
Americans had tired of the typical answers. They knew that government alone couldn’t cure our social and economic ills. But after 12 years of Republican rule, they also knew that government neglect was making things worse. The ‘government is the problem’ mantra proved to be another way of saying to the middle class and the aspiring poor: “you’re on your own.” 
As a candidate for president, I was determined to move beyond the dead-end debate between entitlement and neglect to a policy of empowerment, “a common sense path that offers more opportunity to families in return for more personal responsibility.” That meant, among other things, supporting initiatives that both increased employment and strengthened families. 
Twenty years ago today, barely more than two weeks into my presidency, I stood in the White House Rose Garden to sign the Family and Medical Leave Act (FMLA), which provided millions of Americans with the opportunity to take time off to care for a new child or sick relative. It was then and remains today the embodiment of my governing philosophy of empowerment through opportunity and responsibility. To this day, I receive more thanks from citizens for the FMLA than any other single piece of legislation I signed into law. Between 1991 and 1997, the percentage of full-time employees in large and medium-sized businesses taking maternity leave grew from 37 to 93 percent. By the time I had left office, 35 million Americans had taken leave, and estimates today suggest that number has grown to 100 million. 
They all have a story, like the father who brought his cancer-stricken daughter on a White House tour. He told me she was very ill and probably wouldn’t make it, but the months he’d taken off from work to be with her were the most important months of his life. Or the flight attendant who told me about both her parents falling ill at the same time, with only her and her sister to take care of them. Without FMLA, they couldn’t have done it. She said, “All politicians talk about family values, but I think how your parents die is an important family value.” 
Near the end of my administration, I argued that we needed to find “new ways to provide paid leave to those workers who need to take off but cannot afford to do so.” Most advanced nations provide some form of paid family leave, and it’s helped, not hurt, their economies. A growing chorus is now working on how to make that dream a reality here, and they deserve our support. 
There are few greater joys for me as a private citizen than seeing the impact the FMLA has had on hardworking Americans over the last 20 years. In the face of new economic and social challenges, America found a way to revive what de Tocqueville called “the habits of the heart.” And that may be the FMLA’s most enduring lesson. If we can once again infuse our nation with opportunity for every family, and responsibility from every individual, the foundations of American exceptionalism can survive and thrive in the face of today’s challenges. 
President Bill Clinton
Founder, William J. Clinton Foundation 42nd President of the United States
William Jefferson…

Despite the rise of unemployment, the demographics of the current workforce have significantly changed over the past twenty years.  More spouses and single parents work, allowing for less available people to act as primary caregivers for an ever increasing amount of baby boomers who now need additional care.

This increase in responsibilities on more and more individuals also requires monitoring of their personal well being. The National Family Caregiver Association recommends ten helpful reminders for caregivers.

  1. Caregiving is a job and respite is your earned right. Reward yourself with respite breaks often.
  2. Watch out for signs of depression, and don’t delay in seeking professional counseling..
  3. When people offer to help, accept it.  No one is a martyr. Don't be afraid to suggest specific thing they can do for you.
  4. Educate yourself about your loved one’s condition and how to communicate effectively with doctors.
  5. Recognize the difference between caring and doing. Be open to technologies and ideas that promote your loved one’s independence.
  6. Trust your instincts. Most of the time they’ll lead you in the right direction.
  7. Caregivers often do a lot of lifting, pushing, and pulling. Be good to the physical health of your back and be extra careful. Remember, if you injure yourself, you will be of no use to your loved one.
  8. Grieve your loss, and then allow yourself time to dream new dreams.
  9. Seek support from other caregivers. Knowing you are not alone builds emotional strength.
  10. Stand up for your legal rights as a caregiver and a citizen.
While it's paramount for caregivers to prioritize time to "care for themselves", they must clearly understand their roles in providing quality care to a loved one. You must be ready to assist both your patient's obvious physical and emotional needs, as well as any direct care that may be instructed by the patient's provider.

Another crucial function caregivers must recognize is to provide advocacy services. Integrating patient advocacy into the daily routine of caregiver activities is a challenge. The caregiver needs to be a conduit between the patient and the patient's provider. Listen to your patient and learn to speak on their behalf.  Many patients are unable to adequately communicate their feelings and symptoms to the provider. In this case, it's up to the caregiver to act as the "interpreter". Be their eyes and ears. Many of us have been in the situation where a doctor is directly talking to us, giving us instruction and feedback, only to have missed many of the salient points of the discussion.  An intelligent, healthy advocate, at our side. to ask questions and take notes is critical.

A final reminder for all present and future caregivers. We all age and need assistance. We all get sick. None of us want to be dependent on another individual. But if you can care responsibly with compassion and love, you can offer some grace and dignity we all rightfully deserve.

Stay Informed. Stay Healthy. Stay Alive
- The Patient's Advocate

Tuesday, January 29, 2013

The Future of Health Care Spending

Much of the concern surrounding Obamacare is the ultimate cost of the program. No one knows for sure what the final numbers may be, but it's likely spending will continue to increase until the new system is fully implemented and further evaluated.

A recent Wall Street Journal report suggests that in 2014 U.S. Health Care spending will increase simply because of the additional millions of new people obtaining health insurance for the first time as a result of the initial implementation of the Affordable Care Act (ACA). The recession also contributed to lower than normal spending numbers as many individuals delayed needed services, either because they could not afford them, or they simply did not have health insurance.  

The most recent figures for health care spending are for 2011 where health care accounted for almost 18% of the Gross Domestic Product.  By 2021 this number's expected to rise to 20%. It's important to note that even without the ACA, spending was going to increase. We're an aging population with a tremendous amount of baby boomers heading into the critical care periods of their life.  Every day, another 10,000 people enter the Medicare program as they reach 65 years of age.

In order to fully understand health care spending in the future, it is necessary to identify the major factors that contribute to spending now. How we better manage these components will determine if we're able to eventually lower our medical costs. Most of what accounts for the costs of medical care can be broken down into these areas: Technology, Administrative, Unnecessary care, Fraud, How providers receive payment and Self-preventive measures. Lisa Zamosky summarized each of these areas very well in her Los Angeles Times article. 

While we are the most technologically advanced nation in the world in terms of health care procedures and instrumentation, this comes out a significant price. Michael Thompson of Price WaterHouse Coopers' Health and Welfare Practice in New York points out that while technology has helped other industries reduce and control cots, it has actually had the opposite effect in health care. Everyone, from doctors to hospitals to patients want the newest and best technology. In order to remain competitive in an increasingly competitive battle to deliver the best care, providers strive to always be on the cutting edge with the latest MRI or CAT scan. Cheaper is not the mission here. And the costs associated with these new improved technologies is then passed onto the patient via increased insurance premiums, co-payments or higher deductibles.  The area of technology is one where we have the least amount of control in terms of health care spending.

On the other hand, curtailing administrative expenses can be accomplished by developing a more efficient process in both the provider's office and in the insurance company's processing claims area. The ACA requires insurance companies to spend a minimum of 80% of the health care premium on medical benefits and 20% on administrative expenses for individual and small groups.  This is referred to as the medical loss ratio.  For large groups the medical loss ratio is 85%. Details of how these ratios are developed can be found in this Congressional Research Service report.

Failure to comply with the ACA, brings a penalty to the insurance company with the insured receiving a rebate. In essence, this new law encourages less red tape in the system.

According to The Washington Post annual unnecessary care accounts for $750 billion or one-third of the total $2.6 trillion spent on health care. That number is astonishing. The chart below breaks down all that is considered "unnecessary."


This is a lot of waste, but on the positive side, with the proper review, it can be fixed relatively easily. Misdiagnosis, billing errors and individuals ignoring preventive measures or early detection can all be reduced.  If we don't demand and implement better quality controls on the above components, health care spending will continue to increase at an alarming rate.

The area we have not yet addressed relates to the way we pay providers. The traditional fee for service model does not support a system for controlling health care spending. The fee for service model encourages more utilization.  Providers are paid on the basis of quantity, as opposed to quality measures.  Even if we talk about going to a single payor system of health care, the fee for service model will only continue to encourage more testing, more visits and ultimately increased costs. One of the flaws of the Medicare program is that it does not encourage efficiency and health care cost containment. Because providers end up receiving less money for services provided when treating Medicare patients they too often mistreat, over treat or haphazardly order unnecessary tests.

There are a number of innovative delivery system approaches that are currently being tested to encourage efficiency and quality over the present volume oriented fee for service approach.  The Accountable Care Organization (ACO) is one such approach whereby providers group together to form a more efficient delivery system.  The ACO may bundle payments.  They offer one flat negotiated fee for certain procedures, such as hip or knee replacements in contrast to charging patients and insurers for each individual service involved in the procedure. The ACO works on the premise of developing certain benchmarks by which the provider and insurance company agree upon. Examples of these benchmarks include hospital readmission rates, reduction in rate of infections and reduced emergency room visits. If the agreed upon benchmarks are met, the provider and insurance company split the savings based on pre-negotiated terms. This system begins to encourage meeting quality of care benchmarks, as opposed to encouraging volume oriented fee for service reimbursement.  While the jury is still out on this approach, it is a step in the right direction.

Stay Positive. Stay Informed. Stay Healthy.
- The Patient's Advocate

Monday, January 14, 2013

U.S. Health vs The World

The timing of former President Bill Clinton's Foundation's 2013 Health Matters Conference on Tuesday could not be more appropriate.  Within the last week the National Research Council and the Institute of Medicine released an extensive report on the state of health of the citizens of the United States compared to peer nations around the world. The results are not encouraging for us. In fact, they're down right lousy and embarrassing.

For a country that prides itself on being the very best, when it comes to America's individual and collective health, we're extraordinarily supremely unhealthy. As part of his Global Clinton Initiative the former President turned world ambassador and philanthropist joins leading health and wellness advocates to promote and improve individual healthy lifestyles in the home, the community and the workplace.

This report from the NRCIM has nothing to do with the current topical discussions that involve the quality of our healthcare or our rising costs. Instead, the data reflects individuals's personal health maintenance, taking into account factors like obesity, diet, mortality, etc.

The news is bitterly morbid for American men whose life expectancy is lower than 17 other of the world's wealthiest countries.  When it comes to American women, only the Danish have a shorter life span. Here's the link to the detailed report that explains more of the determining factors behind our national deficiency.

When you see startling statistics such as these you cannot expect to behave like nothing's wrong. As a country and as individuals we must reexamine how we live, how we eat and how we exercise. The on going discussions around Health Care absolutely must include areas like nutrition, physical fitness and mental well being. It's all part of the larger issue.  If nothing else, this report should serve as a national wake-up call. Our health and future depend on it.

Stay positive. Stay informed. Stay healthy.
- The Patient's Adovcate