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Fixing Social Security

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Brian J. Knabe MD

By Brian J. Knabe; MD CMP© CFP®

http://www.SavantCapital.com

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These days, as Congress debates the debt ceiling issue in our current political atmosphere, Social Security is suddenly front page news again.

Social Security

The first thing to understand is that there IS a solvency problem with Social Security.

Alice Munnell, Director for the Center for Retirement Research at Boston College University points out that, according to the Congressional Budget Office, the Office of Management and the Budget and the Government Accountability Office, the benefits promised to future retirees exceed the scheduled taxes that are projected to be taken in.

In fact, last year, Social Security began paying out more in benefits than it received in payroll taxes–years earlier than projected, due to the 2008 Great Recession.

The second thing to understand is that Social Security is not going away; too many people today and in the future depend on it for a crucial part of their retirement income.  Munnell notes that Social Security accounts for 87% of non-earned income for the poorest third of households over age 65, 70% for the middle third and 37% for the highest third.

The Question

So the question becomes: how can Congress bring Social Security back into revenue balance.

To help illustrate some of the trade-offs, the American Academy of Actuaries web site includes a game that allows all of us to fix Social Security–you can make your own adjustments here: http://www.actuary.org/content/try-your-hand-social-security-reform and discover a variety of ways to balance the books, some more painful than others.

Options:

You could, for example, move up by one year the day when people have to wait until age 67 to claim maximum benefits, and after that index the retirement age to maintain today’s ratio between expected retirement years and work years.  This, alone, would solve 20% of the funding problem, and some would argue that it should have been done years ago.

As an alternative, you could reduce the annual cost of living adjustments in Social Security payments by half a percentage point.  This would reduce the projected deficiency by 40%.  Of course, it would also erode the purchasing power of elderly people who count on Social Security for a significant part of their income.

We could reduce benefits by 5% for future retirees, which would solve 31% of the problem.

Or we could reduce the benefit formula for the top half of earners, who theoretically are less dependent on Social Security in retirement.  That would solve 43% of the projected Social Security deficit.  It would also mean that people who are able to fund a comfortable retirement will get much less out of the system than they put into it.

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Mature Woman

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On the other side of the ledger, we could incrementally increase the revenues going into the Social Security system.  For instance, if we raised the payroll tax rate from the current 6.2% to 6.7% for employees and employers, 48% of the shortfall would go away.  As an alternative, we could tax Social Security benefits like we do IRA and pension benefits, which would make up 14% of the projected shortfall.

Sans Fiscal Health 

As you can see, none of these proposals, by itself, will bring Social Security back to fiscal health.  If you’re looking for an out-of-the-box solution to add to the mix, consider an article in the Christian Science Monitor, where former U.S. Secretary of Labor Robert Reich notes that a big (and largely undiscussed) problem with Social Security is the shifting balance of workers paying into the system to retirees collecting from it.

Forty years ago, he says, there were five workers for every retiree; today, there are three.  In 20 years, perhaps less, the ratio will be 2:1–that is, every two workers in America will have to pay whatever is required to support one retiree’s Social Security benefits.

How would you fix this problem? 

Reich proposes that we allow more immigrants into the U.S.–that immigration reform and entitlement reform are linked. As the deficit debate goes forward, you’ll hear a lot more about how to “fix” Social Security.

Assessment

Consider this a cheat sheet on the options that various parties will eventually put on the table.

Sources: Alice Munnell:  http://blogs.smartmoney.com/encore/2011/07/11/saving-social-security-raising-taxes-vs-cutting-benefits/?mod=wsj_share_twitter

Robert Reich: http://www.csmonitor.com/Business/Robert-Reich/2010/0411/Immigration-Could-it-solve-Social-Security-Medicare-woes

Conclusion

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How to Die Like a Doctor!

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Brian J. Knabe MD

By Brian J. Knabe; MD CMP© CFP®

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If you want to fix the problem of rising costs in the U.S. healthcare system, or at least reduce the looming Medicare/Medicaid entitlement burden, there’s a surprisingly easy solution.

Washington

In Washington policy circles, it has been estimated that more than 80% of all the dollars spent on healthcare in the U.S. are incurred in the last nine days of a person’s life. Many times, the money is spent keeping a person alive in a vegetative state, prolonging an incurable illness or painful conditions where there is little to no chance of recovery. The money is not just wasted; it may actually be used to prolong suffering when recovery is not an option. It doesn’t have to be this way.

Forbes

In an ongoing blog on the Forbes website, emergency room physician and financial planner Carolyn McClanahan MD tells us that doctors are among the best at avoiding this dismal fate at the end of their lives by taking a few simple recautions.

Dying like a doctor, she says, starts with understanding that we all get sick and die. Most people know this, but don’t realize it deep down, which is why individuals who experience near-death experiences–making death a more prominent part of their awareness–often choose to live more vital and productive lives thereafter, determined to make every second count.

As McClanahan says,

“When we live with no regrets, death isn’t scary.”

Doctors also see first-hand situations in which an unconscious person goes through a battery of procedures that keeps them alive until Friday, when they otherwise would have died the previous Tuesday.

McClanahan recommends that laypersons get a closer look at the transition from life to death by volunteering at your local hospice. Finally, doctors understand the power of documentation. They make sure they have a living will that describes how they want to be treated when faced with a serious accident or illness. They’ll have an advance directive which provides written instructions regarding their medical care preferences. In an earlier blog post, McClanahan stated that it is best to focus on outcome rather than actions.

Her favorite example is the routine question: “Do you want CPR?” –which, she says, seldom works at the end of life, will crush the bones in your chest and will become just another charge on the “superbill” the hospital sends the insurance company after your death.

The Flip

If instead you turn the question around, and make it: “What type of lifestyle is acceptable to you?” –then you might answer, “As long as I can use my brain, even if I can’t move, I want to be kept going.” That means you would be okay being a quadriplegic, but don’t want to be kept alive in a persistent vegetative state. Both of these documents will be entrusted to members of the family, or placed in a safe place that is accessible to your loved ones. They’ll go alongside a medical power of attorney, which empowers a friend or relative to make financial decisions when you are unable to.

Doctors also know to designate a health care agent who understands their wishes and will act accordingly when the hospital medical team presses for permission to keep them alive when there is little chance of recovery.

McClanahan tells the story of her own father, who was diagnosed with lung cancer. The doctors recommended chemotherapy and radiation. When he decided to forego this painful treatment, the doctors were indignant, and predicted he would be dead within six months. He lived three more years, and the hospice was a blessing at the end. He was one of the few non-physician Americans who had the knowledge and the documentation to die with dignity.

Assessment

Like a doctor. 

Conclusion

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Are you Being “Admitted” to the Hospital?

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OR … just “Observed”?

Brian J. Knabe MD

By Brian J. Knabe, MD, CMP©, CFP®

Savant Capital Management

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Much attention has been given in recent months to the unintended consequences of healthcare rules and laws.  Most of this has centered on the Affordable Care Act—employers discontinuing health plans for their employees, individuals being dropped from their privately purchased insurance, and other ill effects.  One subject that has not received much press, but which may affect many seniors, is changing rules for Medicare.

Medicare

Patients usually assume when they spend a night or more in a hospital that they have been “admitted.”  However, this is often not the case.  Medicare regulations and statutes require physicians and hospitals to predict at the time of initial hospitalization how long a patient will stay in the hospital.

A short stay—for a night or two– is classified as “observation,” while a longer stay can be classified as an “admission.”  While the difference between these may not be a primary concern for a sick patient wanting to receive necessary evaluation and treatment, it can make a significant difference for your pocketbook.

Observation status

Observation status is considered “outpatient” treatment, and as such can expose Medicare patients to unexpected expenses.  As outpatients, visits under observation status are not covered under Medicare Part A, which pays for hospital charges above a $1,184 deductible.  These outpatient services are billed under Medicare Part B, which requires patients to pay 20% of the cost and imposes no cap on their total out-of-pocket expenditures.

Moreover, observation patients must pay out of pocket for the medication they receive in the hospital.  Those with Medicare Part D prescription-drug plans can file claims for reimbursement, but they may receive little or no refund if their Part D plan doesn’t cover those specific medications.

SNF

Another unexpected consequence of hospital observation is subsequent nursing home coverage.  A stay in a Skilled Nursing Facility (SNF) is often covered by Medicare, as long as certain criteria are met.  One of those criteria is whether the SNF stay was preceded by a “qualifying hospital stay.”  An admission to a hospital might meet this criterion, but an observation stay will not, even if it extended for a number of days.  When a patient who meets Medicare’s admission requirement moves to a SNF, the program covers 100 percent of the first 20 days.  Patients are responsible for $152 daily co-pays for the next 80 days, if necessary.  On the other hand, patients leaving the hospital for a SNF after an observation stay pay the full cost out of pocket.

WSJ

According to a recent Wall Street Journal article, from 2004 to 2011 the number of observation services administered per Medicare beneficiary rose by almost 34%, while admissions per beneficiary declined 7.8%.  Why does this difference between admission and observation matter to hospitals?  It comes down to payment.  Hospitals are reimbursed less for outpatient services.  However, if it is determined after a hospitalization that a patient should have been kept under observation rather than admitted, Medicare will often deny payment to the hospital for the entire bill.  So hospitals are motivated to get it right, at least according to Medicare regulations.

hospital bills

What  to Do?

So, what can you do to protect yourself as a patient?  At the time of hospitalization, ask your physician whether you are being admitted or kept under observation.  Ask to speak to a case manager about the proper status of the hospital stay.  Ask your doctors if they suspect that rehabilitation services will be needed after the hospitalization, and if so, request their help in getting the decision to “observe” reversed prior to hospital discharge.

Assessment

For additional help, see the “Self Help Packet for Medicare Observation Status” at www.medicareadvocacy.org.

See more at: https://www.savantcapital.com/blog/are-you-being-admitted-to-the-hospital-or-just-observed/#sthash.EOOiPWOA.dpuf 

Conclusion

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An Emerging Values-Based Healthcare Payment Model

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Understanding Non-Traditional Physician Reimbursement Paradigms

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According to Brian Knabe MD, Mark Fendrick, MD and Michael E. Chernew, PhD, instead of the one size fits all approach of traditional health insurance reimbursement, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible.

The New Model

In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit. Smarter benefit packages are designed to combine disease management with cost sharing to address spending growth.

Assessment

Today, whether independent or employed, physicians can pursue creative compensation models not like the one briefly described above and unknown just a decade ago.

Conclusion

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ME-P Thought-Leader [MD] in the News

Brian J. Knabe MD of Savant Capital Management

By Max Alexander

Dow Jones Newswires; 212-416-2245 Brian J. Knabe MD

Lots of doctors get burnt out dealing with the business end of medicine. But Brian Knabe, a family practice physician in Rockford, Ill., had such a passion for crunching numbers that he became a financial planner.

Knabe, 42 years old, still sees patient’s two half-days a week. He also teaches residents for another half-day at the University of Illinois – College of Medicine.

Most of the week, he’s a certified financial planner with Savant Capital Management.

“I hear all the jokes,” says Knabe, “the most popular being some version of, ‘Hey I guess my portfolio’s doing so badly, they had to bring in the doctor.'”

When the laughter dies down – it doesn’t take long – people often ask what motivated him to transition from medicine into finance.

His short answer is what you’d expect from a wealth adviser: “I wanted to diversify my career.”

The long answer includes a lifelong passion for math that runs in the family. Knabe’s father and brother are both engineers, and the doctor himself majored in bioengineering at Marquette University. “In college, I loved calculus, statistics and differential equations,” he says.

Growing up in Rockford, his best friend was Brent Brodeski, a partner at Savant, and Knabe had been a client of the firm since 1995. “For years, I joked with Brian, ‘If you ever get bored with medicine, you can join us,'” says Brodeski. “Three years ago he called and said, ‘I’ll take you up on that.’ I was floored.”

Knabe wasn’t bored with medicine. “I love taking care of patients, and the intellectual stimulation of the field,” he says. “So I told the partners at Savant that I would only do this if they allowed me to continue practicing medicine part-time.” Meanwhile, he went back to Marquette and got his CFP credentials.

About half of Knabe’s financial clients are doctors, who appreciate his insider’s knowledge of their work and financial issues. Both fields involve privacy and trust, he notes, and both involve planning for the future. They also involve an element of uncertainty.

Sometimes his advice is specifically health-related.

“One client I was working with was a couple where the husband had a terminal illness,” recalls Knabe. “I worked closely with the family in planning living will issues and durable power of attorney for health care. I’ve helped other clients wade through health insurance and disability issues.”

Yes, financial clients do sometimes ask him for medical advice, but he stops them before they can unbutton their shirt.

“If they have a problem and need a diagnosis, I’ll tell them where to go to get a second opinion,” he says.

Link: http://online.wsj.com/article_email/BT-CO-20090914-711325-kIyVDAtMEM5TzEtNDIxMDQwWj.html 

Managing Editor’s Note:Become a CMP

Dr. Knabe is also enrolled in the www.CertifiedMedicalPlanner.com program in health economics and medical practice management for financial advisors and healthcare consultants.

Conclusion

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