Patient Advocate

This Could Be the Obamacare Outcome we’ve All Been Waiting For

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This often-overlooked long-term goal of Obamacare may be finding the mark according to this latest study from the American Cancer Society.

The third open enrollment period for the Affordable Care Act, best known as Obamacare, has been ongoing for roughly five weeks now. And as seems to be the trend around this time of year, more questions than answers appear to be swirling around healthcare’s law of the land.

Big changes lead to an uncertain future

Obamacare is facing a number of changes in the 2016 calendar year, and, frankly, no one is certain yet how those changes might affect enrollment or patient mix for insurers.

For example, insurance premiums are rising at about their fastest rate in about a decade. The Great Recession held premium rate inflation in check for years, but the failure of more than half of Obamacare’s health cooperatives, coupled with many low-cost insurers coming to the realization that their rates were unsustainably low, are leading to big premium hikes in the upcoming year.

Data from the Washington Examiner showed that 231 insurers requested double-digit percentage premium price hikes in 2016 compared to just 121 in 2015. Furthermore, the magnitude of these hikes — 61 plans are looking for a minimum premium increase of 30% this year — is much higher than 2015. In short, there’s concern that higher premiums could reduce the affordability of the program for those who don’t qualify for a subsidy, leading to a higher uninsured rate.

Meanwhile, the employer mandate will be fully implemented on Jan. 1, 2016. The employer mandate will require that businesses with 50 or more full-time-equivalent employees (FTE’s) offer eligible health coverage to those FTE’s and their dependents under the age of 26, as well as provide financial assistance in instances where low-income FTE’s would be paying more than 9.5% of their modified adjusted gross income out of pocket toward their premium. If qualifying businesses fail to follow the rules, they could be looking at a $2,000 to $3,000 fine per employee.
The big question here is how businesses will respond. Will bigger companies step up and supply health insurance for their workers or will we see layoffs, hour cutbacks, or a move to private health exchanges? Obamacare’s big changes in 2016 are leading to a seemingly uncertain enrollment outlook in the near term.

Obamacare’s incredibly important goal that you probably overlooked

The easiest way to measure the success of Obamacare has always been by its overall enrollment totals. Obamacare was first and foremost designed to reduce the number of uninsured and to utilize the individual mandate and employer mandate to make that happen. The Centers for Disease Control and Prevention reported in Q1 2015 that just 9.2% of U.S. adults remained uninsured, including Medicare patients, which is the lowest figure on record. By this token, Obamacare would appear to be hitting its primary goal.

But there’s an even more important long-term goal that’s often lost on critics when discussing Obamacare’s success or failure — namely, the impact that preventative (and earlier) medical access could have on reducing long-term medical costs.
For insurers, Obamacare is a bit of a give and take. Insurers are enrolling more people than ever, and they’re also being required to accept members with pre-existing conditions. The result is that some insurers, such as the nation’s largest, UnitedHealth Group, are dealing with adverse selection and losing money on their individual marketplace plans because they’ve enrolled a large number of sicker individuals. Even though some of its large peers such asAnthem are healthfully profitable, the margins most insurers are generating on Obamacare plans (if they’re even profitable in the first place) are relatively small.

Now here’s the catch: In exchange for spending more money on their members up front, it’s possible that chronic and serious diseases that are the primary expense culprit for insurance companies can be caught before they become a serious issue. Thus, while health benefit providers may be spending more now than they would like to, their long-term outlook is also looking brighter presuming the current generation of members is now going to be healthier than the last generation given expanded access to medical care.

This could be the outcome we’ve been waiting for.

This last point sounds great on paper, but it’s difficult to prove that Obamacare is really making a dent in lowering long-term healthcare costs, especially since it’s only been the law of the land for about two years. All that consumers and critics can focus on at the moment are the rapidly rising premium prices.

However, a new study from the American Cancer society that was published online in the Journal of the American Medical Association late last month appears to show that there is a correlation between Obamacare’s expansion and a higher rate of cervical cancer diagnoses in select patients.

Researchers from the Department of Epidemiology at Emory University and from the ACS’ Department of Intramural Research analyzed a large database of cancer cases within the United States, separating cervical cancer diagnoses for women ages 21 to 25 in one group from cervical cancer diagnoses in women ages 26 to 34 in the other cohort. The reasoning behind this split? Persons under the age of 26 are still eligible to be covered under their parents’ health plan under Obamacare, and thus the expansion of this dependent clause should give researchers a reasonable correlation of how well Obamacare is affecting the rate of cervical cancer diagnoses.

After examining cervical cancer diagnosis rates for both cohorts before and after the implementation of Obamacare, researchers noted that there was a substantial increase in the number of cervical cancer diagnoses for women ages 21 to 25, whereas the age 26-34 cohort had a relatively consistent number of diagnoses before and after Obamacare’s implementation.

On the surface, a rising rate of cervical cancer diagnoses may not sound good at all. But, in a different context it could be just the news we’ve been hoping for. The key to beating cervical cancer is discovering it early, and presumably being able to stay on their parents’ health plans until age 26 helped the 21- to 25-year-old cohort gain this vital medical access. It’s possible that this early diagnoses not only saved lives, but for insurers that it kept them from shelling out big bucks in mid- to late-stage cancer treatments.

Keep in mind that this is just one example, and one example does not make a trend. However, it’s long been postulated that reducing the barriers to health insurance would lead to a higher medical utilization rate for consumers and a better chance of discovering potentially serious and chronic conditions at an earlier time, thus saving the patients’ lives and cutting insurers’ long-term medical expenses. It’s possible we could be witnessing the first signs of that.

Understandably, we’ll want to see additional studies emerge that examine disease diagnosis and treatment rates in a pre- and post-Obamacare setting so we can make a conclusive ruling as to whether or not Obamacare could actually lower long-term healthcare costs and improve long-term patient survival rates. The initial signs, though, are very encouraging.

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The Hospital-Dependent Patient

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By PAULINE W. CHEN, M.D.

Interesting piece about the unintended cost and consequences of hospital re-admissions.  Spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent” adding great cost to the healthcare system.

“He’s back?” my colleague asked, eyes widening as she passed the patient’s room. “He’s in the hospital again?”
Slender, pale and in his late 60s, the man had first been admitted nearly a year earlier with pressure in his chest so severe he had trouble breathing. When his heart stopped, doctors and nurses revived him by injecting the latest life-saving medicines into his veins and applying the newest electrical defibrillator paddles to his chest.

Within minutes, the cardiology team arrived, but when the blockage in the arteries of his heart proved too extensive for even their state-of-the-art techniques and equipment, they handed him off to the waiting surgeons. The surgeons, in turn, cooled down his heart until it stopped beating, sewed in bypass conduits with threads finer than human hairs, restarted the heart with a few well-placed jolts of electricity and then transferred the patient to the cutting-edge intensive care unit to recover.

The man survived. Sort of.

Weakened by this string of emergencies, he required a breathing machine for several days. When excess fluid in his lungs caused shortness of breath, he needed intravenous diuretics. When his heart began beating erratically, he was obliged to take a finely tuned cocktail of heart medications. And when his chest wound became infected, he had to return to the operating room.

Finally, after nearly two months in the hospital, he was discharged to a skilled nursing center. But then a urinary tract infection made him dizzy and confused, and he went right back to the hospital, beginning a cycle of discharge and re-admittance that would persist for almost a year.
To many of us who had cared for the man, it seemed as if he had spent more days in the hospital than out.

“What kind of life is that?” my colleague asked as we stood in the hallway and watched the man’s wife help him once again put on his hospital gown and pack away his street clothes. “You’ve got to wonder,” she whispered, “did we really do him a favor when we ‘saved’ him?”
I was reminded of the frail man and the many patients like him whom I have known when I read a recent Perspective piece in The New England Journal of Medicine titled “The Hospital-Dependent Patient.”

Over the last 30 years, American hospitals have become a showcase of medical progress, saving lives that not long ago would have been lost.

“Rapid response teams,” drilled in precision teamwork and the latest techniques of critical care, have become commonplace. Cardiac and respiratory monitors, once found only in intensive care units, are now standard equipment on most wards and even in many patient rooms. CAT scanners and M.R.I. machines, once rare, have become de rigueur, with some hospitals boasting duplicates and even triplicates.

But up to one-fifth of patients treated with these new medical advances and then deemed well enough to leave the hospital end up being re-admitted within 30 days of their discharge, at considerable cost. Insurers and third-party payers have begun penalizing health care systems for these quick re-admissions; and hospitals, in response, have begun significant efforts to improve the transition from hospital to home, creating clinics that remain open beyond usual working hours and marshaling teams of care coordinators, post-discharge pharmacists and “care transition coaches.”

The problem persists, though, because our spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent,” according to the authors of the Perspectives article.

Hospital-dependent patients are those who, a generation ago, were doomed to die. Now they are being saved. But they are not like the so-called hot spotters, a group of patients more commonly associated with frequent re-admissions who return to the hospital because of inadequate follow-up care, failure to take prescriptions correctly or difficult socioeconomic circumstances. Instead, hospital-dependent patients come back because they are so fragile, their grasp on health so tenuous, that they easily “decompensate,” or deteriorate under stress, when not in the hospital.

Medical advances can snatch them from the clutches of death, but not necessarily free them from dependence on near-constant high-tech monitoring and treatments.

“They are like a house of cards,” said Dr. David B. Reuben, lead author of the article and chief of the division of geriatrics at the Geffen School of Medicine at the University of California, Los Angeles. “When one thing goes wrong, they collapse.”

Not surprisingly, hospital-dependent patients feel more secure and are happier in the hospital than at home. While clinicians and even family members may judge theirs a diminished existence, these patients find their quality of life acceptable, relishing their time with friends and family or engaged in passive hobbies like watching sports or reading the newspaper, albeit in the hospital.

Over time, however, their recurring presence can result in conflicted feelings among those who were responsible for saving them in the first place. Some clinicians even begin to resent their obligation to continue administering resource-intensive care. “Physicians are socialized to cure patients, then move on,” Dr. Reuben observed. “They want to treat patients, not adopt them.”

Dr. Reuben and his co-author offer potential solutions, such as specialized wards or facilities that would be more intensive than skilled nursing homes yet less costly than a hospital. But they are quick to add that more research must also be done. Their concept of “hospital-dependency” is a new one, so no research is available to help identify patients at risk of becoming hospital-dependent, estimate the percentage of early re-admissions they are responsible for or calculate the costs they incur.

Even without studies, it’s clear that the numbers of these patients are increasing. With every triumphant medical advance, there are patients who are cured but who remain too fragile to live beyond the immediate reach of the technology that saved them. Until we begin making different decisions regarding how we allocate our resources, their presence will be a constant reminder of which medical research and health care we consider worthy and which we do not.

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No Easy Answers on Financing Long – Term Care

Doug

By JUDITH GRAHAM, NY Times

This article points out the difficulty in financing long term care for the elderly.  Experts believe more focus should be on finding ways to provide affordable care within the efforts to reform Medicare and Medicaid.  For now, families continue to bear the brunt of the cost associated with caring for the elderly.

The federal Long-Term Care Commission published its full report on Wednesday, but it did little to change the perception that substantial relief for caregivers will be a long time coming.

The commission had endorsed a package of 28 recommendations late last week, prior to the release of the full report. Among other measures, the recommendations call for recognizing caregivers as members of “care teams,” including information about caregivers in patient records, assessing caregivers’ need for support, and making services like respite care more widely available.

But this group of 15 experts couldn’t agree on how to pay for long-term care services needed by frail older adults or people with disabilities. The full report doesn’t change that.

Currently, only those who are impoverished and qualify for Medicaid get significant assistance from the government for long-term care. For the most part, middle-class families are left to bear the burdensome expenses: $18 an hour on average for homemaker services, $19 an hour for home healthcare aids, $3,405 a month for assisted living, $230 a day for a private nursing home room, according to the latest report from Genworth Financial.

How to ease this financial burden was the most important issue facing the commission. In the end, the report proposed two alternatives: some kind of government insurance program for long-term care, or some kind of private insurance option. Then commission members essentially threw up their hands, admitting they couldn’t agree.

When my colleague Paula Span wrote about the commission earlier this year, she asked whether its work would elicit a yawn or a cheer. For many, the answer is neither. Even some commission members feel a sharp sense of frustration and disappointment.

One is Judy Feder, a professor of public policy at Georgetown University, who voted against the commission’s final recommendations on the grounds that they didn’t fulfill Congress’s charge to come up with a comprehensive solution. I asked her about a statement from six of her fellow commissioners insisting that any new long-term care program not enlarge public budgets.

“The current system has a budgetary implication,” Dr. Feder said. “It sticks it to families.”

Another disappointed member is Judith Stein, executive director of the Center for Medicare Advocacy. “The vision in the majority report is not much more than we have now,” she said. “It is, ‘Plan, understand, think about savings and insurance, and provide for those who are impoverished.’ That kind of approach doesn’t meet our long-term care needs now, and it won’t meet them in the future.”

While several of the commission’s recommendations are welcome, they will make a difference only “around the margins,” Ms. Stein said.
Families will bear the consequences, said Ms. Stein and other experts. Elderly spouses will continue to struggle to care for each other, and adult children will strain to balance jobs and the needs of frail parents and their own children. Untold numbers of aging Americans won’t get enough care, and caregivers will suffer from stress and depression, endangering their own health.

If a public insurance program is unaffordable, as several commission members claimed, might the private market supply a solution to the aging population’s need for affordable long-term care? That seems unlikely. Premiums for private long-term care insurance have been rising dramatically, policies are becoming more restrictive, insurers have been exiting the market, and bureaucratic red tape makes it difficult for many individual and families to receive expected benefits.

Financially, the only way to make private insurance work is to spread risk over a wide base of policy holders. But the cost of long-term care coverage makes it unlikely that millions of healthy people will purchase policies. This was the economic calculus that doomed the Class Act, the voluntary long-term care insurance program that was originally part of the Affordable Care Act.

Is there a way forward? The long-term care commission recommended two options: convening a White House conference on aging to consider long-term care policies, and establishing yet another advisory committee to continue its work. But, said Dr. Joanne Lynn, a geriatrician who directs the Center for Elder Care and Advanced Illness at the Altarum Institute, “The administration has shown no interest in having that happen, and here we are on the cusp of the largest generation in history growing old.”

She believes that it’s a mistake to separate long-term care from broader reforms of Medicare and the health care delivery system. The two systems of caring for people with disabilities and older adults need to be much more tightly integrated, Dr. Lynn said. Savings from eliminating inappropriate medical care — by some estimates, as much as one-third of all care — could be used to finance the expansion of long-term care services, she suggested.

As for another commission, is there any reason to hope it will be more successful in tackling critical issues when advocates of smaller government are committed to standing against a new federal insurance program for long-term care that might rely, at least in part, on public financing?

“I think this will be a hard discussion, but it is one that we as a country will have to grapple with,” said Dr. Bruce Chernof, the commission’s chairman and president of the SCAN Foundation in California. He sees the seeds of a potential compromise embedded in the commission’s report. The two primary financing options considered by the commission share “some commonalities,” he said, including agreement on the need for strong public programs and a role for the private sector.

“If you look carefully at these two perspectives, you can begin to see a way forward.”

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Tips for Lowering Your Medical Bills

J Roberts

Don’t be intimidated by high medical bills. What patients don’t realize is a review to find errors and working with the provider can often enable you to reduce medical bills. To enhance your outcome, enlist the services of a medical bill negotiation expert. With the help of a professional who can provide data, most providers will negotiate and offer some type of discount on out-of-pocket medical expenses. Here are some excellent tips that every health care consumer should know when faced with large and expensive medical bills.

By Alice Park, Time Magazine Online

It doesn’t happen often, but occasionally you can catch a mistake on a restaurant check or a miscalculated receipt from the grocery store. Hospital bills, however, are another matter: as many as 8 out of 10 bills for health care services contain errors, according to Medical Billing Advocates of America. Since Americans spend nearly $7,000 per capita on health care every year — and since these expenses climb steadily, at an average annual rate of 6.5% — it’s probably worth scrutinizing the remittance from your last hospital visit. It just might save you hundreds, if not thousands, of dollars.

According to medical-billing advocates, who are the health care world’s equivalent of tax-refund specialists, there are ways to protect yourself from huge health care expenditures both before you’re seen by a doctor and after you receive your bill. “When you are in the hospital, you should concentrate on getting better,” says Kevin Flynn, president of HealthCare Associations, a company that helps patients decipher their medical bills. “Do what is best medically first, then worry about the finances second.”

At the emergency room or in the hospital:

If you are insured, ask to be seen by a doctor who participates in your insurance plan. Just because a hospital is considered in-network by your plan doesn’t mean that all the physicians who work there are as well. This may not always be possible, but if your preference is noted in your file, once you receive your bill, you may be able to negotiate with the hospital to accept your insurer’s higher in-network reimbursement rate, leaving you with a smaller financial responsibility, even if you are seen by an out-of-network doctor.

For the same reason, if you are able to, ask to have any lab testing that is sent outside the hospital to be sent to facilities that participate in your insurer’s plan.

If possible, ask about the tests the doctor or nurses are ordering. If a less expensive test can provide the same information, then request that option. In some cases, for example, less expensive ultrasound tests are just as effective as costly CT scans.

Once you get your bill:

Always ask for an itemized bill so you can see every charge.

Ask for an explanation, in writing, from the hospital’s billing department for any disputed charges.

If you go to the hospital at night and end up being admitted after midnight, make sure your charges for the room start on the day you start occupying the room.

Check the level of room for which you were charged. Hospitals charge for ER services by level, depending on the amount of equipment and supplies needed, with Level 1 requiring the fewest (e.g., a nosebleed) and Level 5 representing an emergency (trauma, heart attack). Question the level indicated on your bill and ask for a written explanation of why that level was billed. Hospitals have their own criteria for determining levels and should make this available upon request. “They don’t freely hand this information out, but they will send it to you if you ask for a written response,” says Pat Palmer, founder of Medical Billing Advocates of America.

Doctors also charge for ER services by level, also ranging from 1 to 5. Their levels are standardized, and physicians are required to meet three criteria to justify billing at each level. Question the level listed on your bill and ask for a written explanation of why that level was billed by your physician.

The hospital level should be equal to or lower than that of the doctor-billed level; if it’s higher, that’s a red flag that there may be a billing error.

Question charges for what seem like routine items, such as warm blankets, gloves and lights. These should be included as part of the facility fee.

Question any additional readings of tests or scans. You should be charged only once for one doctor’s reading of a scan, unless it is a second opinion or consultation.

If you received anesthesia, check that you were charged for only one anesthesiologist. Some hospitals use certified registered nurse anesthetists (CRNAs) but require that an anesthesiologist supervise the procedure, so some bills will contain charges from both, which amounts to double billing.

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Affordable Care Act Rate Shock?

Doug

By Kathleen Phalen-Tomaselli,TheStreet.com

Come January 1 of next year, those with the lowest health insurance risk may be hit the hardest with premium increases as high as 40%. “The rules are changing,” says Robert Zirkelbach, vice president of strategic communications for the American Health Insurance Plans (AHIP) in Washington, D.C.

If you are young, healthy and qualify for non-group coverage, you could face rate hikes forcing you to reconsider how you spend your health care dollars. Here’s what’s happening: The Affordable Care Act, aka Obamacare, reaches maturity the first of the year. Designed to tackle the problem of insuring the nation’s estimated 48 million uninsured in addition to increasing benefits for such services maternity care and reproductive aid—all while lowering premium rates for older Americans. But the new provisions come with a price.

And because of new age rating band requirements tied to the ACA, the 18 to 44 age group’s premiums will increase while the over 57 group will decrease. Today, the ratio for age rating bands is 5:1, which means insurers can charge older individuals five times more than younger insureds. Come January 1, the band ratio reduces to 3:1. Take, for example, a 24-year-old who pays $1,200 annually for non-group coverage today could. He could see an overnight increase to $1,800, while a 60-year-old paying $6,000 today will pay $5,400 in 2014, according to the AHIP.
Nonetheless, in the report “Timely Analysis of Immediate Health Policy Issues” published last month by the Urban Institute Health Policy Center in Washington, D.C., lead author Linda J. Blumberg concludes that such predictions are over inflated. Citing government subsidies available to help defray such increases for those earning less than 400% of the federal poverty level, Blumberg says that subsidies will help this age group obtain expanded coverage. Even so, according to the report, “Premiums for 21-to 27-year-olds are $850 lower under (the)5:1 (age band rating) than under (the)3:1 rating.”

The problem with counting on subsidies to defray higher premiums is that, “40% will not be eligible for subsidies,” says Zirkelbach. He goes on to explain that 7.6 million of those in the non-group category in 2011 earned more than 400% of the federal poverty level.

According to an Oliver Wyman study, the cut-off for subsidies is closer to 250% of the federal poverty level—in other words, those earning less than $25,000. There will be no subsidies for individuals earning more than $50,000.

Along with tax subsidies, the ACA calls for the expansion of state Medicaid programs to help those with lower incomes. But, depending on where you live, this may not be an option. The Supreme Court recently ruled that states can decide on whether they will participate. At this point, many states remain undecided with some governors, like Gov. Tom Corbett(R-PA), saying they have no intention of expanding an already stretched program.

To further compound the issue of higher premiums, the health care reform law includes a new $100 billion sales tax on health insurance that will continue to drive up costs. AHIP predicts this increase may be as high as $300 per family.

The Congressional Budget office says the taxes will, “largely be passed through to consumers in the form of higher premiums.” A 2011 Oliver Wyman analysis estimates that this tax alone—not accounting for age rating bands or expanded coverage—will increase premiums over a ten-year period by $2,150 for individuals and an average of $5,080 for families.

Currently, federal and state governments are establishing health care exchanges—much like a one-stop health insurance supermarket—and individuals will be able to select plans starting October 1.

What are your options?

Pay the higher premiums that will also offer you more coverage. Opt-out of coverage and pay the federal uninsured penalty of about $95 in 2014. Or choose a catastrophic plan available for those up to age 27.

What does Zirkelbach hope for? A repeal of the health care tax and a phasing in of the age rating bands. Is there still time to hope? “It’s hard to say,” he says. “Maybe when taking a closer look at this they will re-visit these issues.”

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Health Care Reform Rules Give Patients A New Bill Of Rights

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Health Care Reform initiatives have yielded a new “Patient Bill of Rights” since November. There will be a great number of changes enacted in 2013 leading up to 2014 when coverage mandates, state insurance exchanges and tax changes take effect for health care. Sound confusing?, It certainly will be. In the meantime, “Know your rights” and check back with us periodically to learn how to navigate health care cost and confusion.

Jeffrey Young – Huff Post Business – 11/20/2012

Health insurance consumers won’t be discriminated against because of pre-existing conditions, can’t be charged more because of gender and will be guaranteed a basic set of benefits under historic new federal regulations published Tuesday.

Think of them as the Patients’ Bill of Rights that eluded former President Bill Clinton more than a decade ago. The regulations carry out the promises of President Barack Obama’s health care reform law, which will extend health insurance coverage to 30 million people over a decade and outlaw some of the industry’s most notorious practices.

Health insurance companies, state regulators and consumer advocates have eagerly awaited these rules since Obama enacted the health care overhaul in March 2010.

The details contained within the 331 pages of regulations are crucial for health insurance companies and states preparing for the new options that will be available to uninsured people and small businesses starting in 2014. The health insurance exchanges, online marketplaces where consumers can shop for plans and determine whether they qualify for tax credits to pay for private insurance coverage or Medicaid benefits, are slated to be open for business on Oct. 1, 2013.

“Americans in all 50 states will have access to an exchange and the benefits of the new law,” Health and Human Services Secretary Kathleen Sebelius said on a conference call with reporters Tuesday. “Beginning in October next year, families and small-business owners everywhere will be able to shop for affordable, quality health coverage.”

The Department of Health and Human Services published three separate regulations Tuesday. Broadly, the rules restate the health insurance market reforms in Obama’s health care law. But health insurance companies and state officials that aren’t actively resisting the implementation of Obamacare need the details to ensure that health insurance exchanges are ready, and health plans available for sale on time.

One lays out the rules requiring health insurance companies to sell coverage to anyone who applies, prohibits charging women more than men, limits how much people must pay additionally based on age, where they live, family size and whether they use tobacco, and guarantees renewal of health coverage every year.

A second set of regulations spells out which benefits all health insurance plans sold on the exchanges must cover — 10 categories of medical care, including emergency services, hospital stays, maternity care, prescription drugs and preventive medicine. In addition, the rule explains how states must designate an insurance product already on the market as a “benchmark plan” to serve as a model for what the new insurance products will cover starting in 2014. This regulation also sets up how health insurance companies must prove their plans will cover at least 60 percent of a consumer’s average annual medical expenses.

The cost of health insurance on the exchanges will be subsidized using tax credits for people with incomes up to 400 percent of the federal poverty level, which is $44,680 this year. People who make up to 133 percent of poverty, $14,856 in 2012, will qualify for Medicaid in states that opt into an expansion of the health program for the poor.

The Obama administration published a third rule on “wellness” programs that employers include in workers’ health benefits, such as discounts to employees who quit smoking, lose weight or lower their cholesterol. The new regulations are designed, in part, to prevent companies from using the programs to set prices to discriminate against workers who don’t meet the wellness programs’ standards.

Publishing these regulations is just one small step toward 2014, however, and major obstacles remain. As of Monday, just 17 states and the District of Columbia had committed to creating a health insurance exchange themselves as the law sets out, according to a tally by the Henry J. Kaiser Family Foundation. The federal government will have to step in, and partially or completely establish these exchanges in the rest of the states, including those run by Republican governors like Rick Perry of Texas who have vowed continued opposition to the law.

“Now that the law is here to stay, I’m hopeful that states and other partners will continue to work with us to implement the law,” said Sebelius, who offered to meet with governors who have outstanding questions about states’ role in carrying out the health care reform law. Florida Gov. Rick Scott (R), an ardent opponent of Obamacare, last week wrote Sebelius requesting a sit-down.

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Same Doctor Visit, Double the Cost

J Roberts

Read about an alarming trend concerning physician practices that will most likely result in greater out of pocket costs to you. Consumers beware; you may pay more for your doctor’s visit than you previously thought. This growing movement is occurring nationwide and is becoming more prevalent as hospitals seek to increase their revenue streams in preparation for the upcoming implementation of the Affordable Care Act.

Insurers Say Rates Can Surge After Hospitals Buy Private Physician Practices; Medicare Spending Rises, Too

Wall Street Journal, August 27, 2012

After David Hubbard underwent a routine echocardiogram at his cardiologist’s office last year, he was surprised to learn that the heart scan cost his insurer $1,605. That was more than four times the $373 it paid when the 61-year-old optometrist from Reno, Nev., had the same procedure at the same office just six months earlier.

“Nothing had changed, it was the same equipment, the same room,” said Dr. Hubbard, who has a high-deductible health plan and had to pay about $1,000 of the larger bill out of his own pocket. “I was very upset.”

But something had changed: his cardiologist’s practice had been bought by Renown Health, a local hospital system. Dr. Hubbard was caught up in a structural shift that is sweeping through health care in the U.S.—hospitals are increasingly acquiring private physician practices.

Hospitals say the acquisitions will make health care more efficient. But the phenomenon, in some cases, also is having another effect: higher prices.

As physicians are subsumed into hospital systems, they can get paid for services at the systems’ rates, which are typically more generous than what insurers pay independent doctors. What’s more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost.

The result is that the same service, even sometimes provided in the same location, can cost more once a practice signs on with a hospital.

Major health insurers say a growing number of rate increases are tied to physician-practice acquisitions. The elevated prices also affect employers, many of which pay for their workers’ coverage. A federal watchdog agency said doctor tie-ups are likely resulting in higher Medicare spending as well, because the program pays more for some services performed in a hospital facility.

Renown said in a statement that cardiologists moving into hospital employment helps “eliminate duplication, improve coordination, and reduce hospitalizations,” and with “more proactive management of patients with heart disease, we are working to improve the health and well being of our patients.”

This year, nearly one-quarter of all specialty physicians who see patients at hospitals are actually employed by the hospitals, according to an estimate from the Advisory Board Co. That is more than four times as many as the 5% in 2000. The equivalent share of primary-care physicians has doubled to about 40% in the same time frame. Traditionally, most doctors who see patients at hospitals are in independent practice.

The structural shift is being driven partly by declining reimbursements for physicians, particularly in certain specialties like cardiology. Doctors are also being pressed to make new investments, such as introducing electronic medical records, and some are attracted to the idea of more regular hours with fewer administrative headaches.

Hospitals say they are bringing in physicians to improve care, integrate services and reduce waste, efforts encouraged by the Obama administration’s federal health-overhaul law. Higher reimbursement is needed in some cases, they say, because it costs more to operate outpatient clinics, which must meet strict regulatory requirements and often treat patients who lack insurance.

“You put a hospital name on something, and the expectations change immediately,” said Richard Umbdenstock, chief executive of the American Hospital Association. Indeed, hospital systems often struggle to break even on their physicians, industry officials said.

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Hospital Bills Disputed by Patients

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As the Health Care Reform Act is implemented over the next two years there will continue to be disputes between Insurers and providers regarding payment. Providers often take large discounts to be in network in return for a greater volume of patients through networks with insurers. It’s a  price for volume trade-off familiar to those who are economics minded. There are often problems in the interpretation and execution of agreements and the associated health care billing practices. Sometimes this results in balance bills being sent to consumers. This article profiles a dispute in New Jersey. Be prepared for other similar disputes across the country.

Meadowlands Hospital bills disputed by patients, Aetna

By  LINDY WASHBURN -The Record, Wednesday, August 15, 2012

Meadowlands Hospital Medical Center has billed hundreds of patients in the last few weeks for care they thought was covered by their Aetna insurance ­policies. The bills — some for thousands of dollars — demand payment within five days.

Aetna’s advice to the recipients: Don’t pay.

Aetna customers who receive bills from Meadowlands Hospital Medical Center are urged to contact the Department of Banking and Insurance at 800-446-7467, or file a complaint online at state.nj.us/dobi/consumer.htm

The dispute shines a light on the complicated terrain that underlies relationships between hospitals and insurers. When new owners bought the Secaucus medical center in December 2010, the state required that the for-profit company make “a reasonable attempt to continue the ­current commercial insurance contracts” for at least a year.

As a result, Aetna says, its contract with the hospital was in force in 2011 — when the bills were incurred — and so the hospital must accept the lower rate it had negotiated as payment in full.

The hospital, however, has told patients they must pay the difference between that contract rate and its regular, higher charges. The letters to those patients state clearly, “You remain obligated to pay all outstanding invoices.” They ask for payment by credit card, certified check or money order.

Meadowlands President Lynn McVey declined through a spokesman to address the contract question.

“Regrettably,” she said in a prepared statement, “a national health insurer is withholding some payments for its plan members who have previously utilized our services. Until this matter is clarified and resolved through negotiations, our reluctant recourse is to follow standard procedure … and seek payment from individuals who were previously treated by [the hospital] and still have an outstanding balance.”

Eileen O’Donnell of North Arlington was told she owed $4,745 for an emergency-room visit in May 2011 to treat a foot injury. That was more than 20 times Aetna’s member rate of $204. Her total responsibility, according to Aetna’s explanation of benefits, was $68.40.

And Kaarin Varon of East Rutherford received a demand from Meadowlands for $13,004 for the care of her son, who was hospitalized with pneumonia last year. Aetna already had paid $1,596 as its contracted rate for his stay.

“I have to admit, I was not sure how a contract dispute had me involved in all this,” said Varon. “But the [Meadowlands billing] representative basically told me it was now my responsibility.”

The state Department of Banking and Insurance is working with the health department to resolve the issue, according to Marshall McKnight, an insurance department spokesman. “Our goal is to protect consumers as much as possible through this process,” he said. Patients who receive the bills are urged to contact the department, he said.

The dispute comes at a time when questions are being raised about finances at the hospital. An independent draft audit for 2011 showed a 10 percent profit margin — four times the state average. A year after MHA LLC, a private investment group, bought Meadowlands in December 2010, the new owners had reversed the $10.4 million operating loss reported for 2010 and posted a $9 million profit, according to the draft submitted to the state.

The dispute also highlights the vast difference between a hospital’s customary charges and the rates negotiated with insurance companies for hospital care. The negotiated rates are often a fraction — 5 percent or 10 percent — of those customary charges.

Some hospitals opt to stay out of insurance contracts as a strategy to increase revenues.

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Rising Health Costs Are a Top Financial Concern of the Affluent

Doug

Affluent consumers confirm that health care cost in not just a top of mind concern, it is the top concern. The Merrill Lynch Global Wealth Management study quoted in this article states that 79% of affluent consumers consider health care as their top financial concern. With the Supreme Court ruling on the Health Care Reform Act coming this week consumers, both affluent and not, must find the health care billing and insurance advocates they trust to navigate the ever changing complexity.

By ANN CARRNS
NY TIMES

Maybe the 99 percent and the 1 percent aren’t so different after all — at least when it comes to fretting about health care.
More than three-fourths of wealthy Americans cite rising health care costs as their top financial concern, a new survey from Merrill Lynch Global Wealth Management finds. This is the third year in a row that affluent Americans polled in the survey have cited health costs as their major financial worry.

A third of those surveyed said they were more worried about the financial strain of a significant health problem, like chronic illness, than they were about how it might affect their quality of life.

Despite those concerns, though, two-thirds of affluent Americans have not estimated what their health care costs may be in retirement — including those over age 50, who are closer to retirement.

Many (41 percent) of the participants who had not yet retired said they expected to pay for their health care costs themselves in retirement. Others expected private health insurance (33 percent) and health benefits from their current or former employer (22 percent) to pay the bill. Roughly 20 percent said they would use long-term care insurance, and 10 percent cited health savings accounts.

The national telephone survey, conducted for Merrill Lynch by Braun Research in December, polled 1,000 adults with investable assets of more than $250,000. (Additionally, about 300 people were surveyed in five markets: Atlanta, Chicago, Dallas, Detroit and San Francisco.) The margin of sampling error was plus or minus 3 percent for the national sample, and 6 percent for the five additional markets.

One reason health costs are getting more attention is that Americans are living longer. The number of Americans who live to be 100 is expected to exceed 600,000 by 2050, according to Census Bureau data cited by Merrill Lynch.

How do you plan to cover health care costs in retirement?

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Medical Debts Put Patients at Risk of Financial Collapse

Doug

The crisis of American health care is not limited to uninsured people, unable to pay for their care. This article shows a deepening problem of working people with insurance unable to pay for treatment of serious illnesses.

By Lindy Washburn – The Bergen Record
First Posted: January 27, 2012

HACKENSACK, N.J. — Frances Giordano found out she had lung cancer in June. After that, the bad news just kept coming.
First, she discovered that even with a good job and health insurance, her medical expenses were more than she could afford on disability.

Then she started slipping into debt, like millions of other Americans who don’t have the cash to cover their medical bills. Hospitals expect to be paid promptly and offer little leeway to insured patients. Unpaid bills go to collection agencies, damaging a person’s credit history for years.

Finally, she learned that fighting for her life was not her only battle or maybe even her toughest. When she finished her chemotherapy in December, she was fired. “Due to changes in business operations,” wrote her employer of more than six years, “We can no longer hold your position open.”

It arrived nine days before Christmas.

“I’m a good person,” the 58-year-old Giordano said in an interview, crying. “I worked hard. Isn’t having cancer enough?”
The crisis in American health care is not limited to hospital emergency rooms where uninsured people wait for care. It also is found in a neat, three-bedroom house in Dumont, N.J., occupied by a widow who worked full time, raised two kids and likes to get her nails done occasionally.

In less than a year, Giordano lost her health and her job. Now, she’s afraid she’ll lose her good credit and her health coverage.

In the lonely hours of the night, she said she thinks about giving up.

Giordano had health insurance throughout her illness. She didn’t have to beg for treatment and was not denied it. She loves the surgeon and oncologist and nurses whose care, she hopes, will give her many more good days with her first grandchild, born in July.

But she may be ruined financially. In this country, people can go broke if they get sick.

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