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My Experience with ObamaCare

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Not a Unique Story – to Date

Rick Kahler CFPBy Rick Kahler CFP® http://www.KahlerFinancial.com

Like millions of Americans, I jumped on Healthcare.gov on October 1 to view the long-anticipated plans on the insurance exchanges mandated by the Affordable Healthcare Act, known as Obamacare. I needed a new healthcare plan and purposely held off buying one in September to compare the coverage and prices of an Exchange plan.

My disappointment paralleled that of thousands of other Americans wanting to do the same. After six tries that day, I gave up. I tried the site multiple times for each of the next six days. No luck.

The Short Form

Finally, on the seventh day, the site actually let me start an application. I chose to go with the “short” form since I was certain I would not qualify for a subsidy.

The short form application took 30 minutes to fill out. There were very few questions about health, just whether anyone in the household smoked. A number of questions had me wondering if I was applying for a passport. These included my Social Security number, race, citizenship, relationships to everyone in the family, and whether I was ever incarcerated.

When I reached the end of the form, I hit “submit,” anticipating that plan options and costs would appear. Instead, I was sent back to the starting page of the form. After 60 minutes of trying to get out of this endless loop, I gave up.

Three More Weeks of Trying

For the next three weeks, I went to the site at least once a day. I was never able to get past the endless loop to view plans or prices. I took a two-week break.

On November 14, I tried again. Success! Well, sort of. No endless loop. Instead, the site said it lost my original application and I needed to complete a new one. After another 60 minutes filling out the application, I ended up stuck in a loop again, unable to view plans or prices, much less choose one.

Giving Up

Frustrated, I decided to give it a rest until the site re-launched on December 1. I figured I would still have plenty of time to meet the December 15 deadline for enrollment.

On December 1, I eagerly popped onto the site. Not only was the site not functional, it had lost my application for the third time.

I gave up.

Enter the Insurance Broker

I phoned my insurance broker. She was able to give me all the information I had tried to get out of healthcare.gov for the past 60 days. She also said my insurance company was canceling my current plan. Obamacare deemed the coverage substandard because it did not cover pregnancy, mental health costs, and pediatric dental and vision costs. Although I don’t want or need any of that coverage, Obamacare gives me no choice.

Prices

My old policy cost $1,192 a month. The new one costs $1,506, which includes $59 a month in mandated surcharges on non-exchange policies to help fund Obamacare. My maximum family out-of-pocket expenses must also increase $208 a month. The total potential increase is a staggering $524 a month.

###

Obama Care

###

A Skeptic

As someone who listened with great skepticism as politician after politician promised that Obamacare would lower health care costs, lower our deficit, and guarantee we could keep any existing plan, I feel sadly vindicated. In March 2010, when Congress passed Obamacare, I paid $660 a month for health care that had better coverage than I have now. For that same coverage today, my premium would be $2,450 a month.

Assessment

Unfortunately, my story is not unique. It is ubiquitous to the average American who has health insurance. Our elected officials and government agencies failed us miserably. So far, there appears to be no relief in sight.

More

Conclusion

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Hospital Information Systems and the PP-ACA

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Extension of Hospital Information Systems Beyond the Hospital

By Brent A. Metfessel MD

Dr. MetfesselThe Patient Protection and Affordable Care Act (ACA), affirmed after the November 7th 2012 presidential election, includes a number of policies and potential projects with the aim of improving quality of care while reducing costs – or at least greatly slowing increases in health care costs from year to year.

Included in this effort are CMS payment incentives for providers that can show care patterns that meet the goals of high quality, cost-efficient care.

HHS and ACOs 

On March 31, 2011, the Department of Health and Human Services (HHS) released a set of proposed new rules to aid clinicians, hospitals, and other health facilities and providers to improve coordination of care for Medicare patients using a model known as Accountable Care Organizations (ACOs). ACOs that are shown to lower health care cost growth while meeting CMS quality benchmarks, including measures of patient/caregiver experience of care, care coordination, patient safety, preventive health, and health of high-risk populations, will receive incentive payments as part of the Medicare Shared Savings Program.

But, in some proposed models ACOs may also be held accountable for shared losses.

Care Co-ordination

Coordination of care means that hospitals, physician offices, and other providers have a complete record of patients’ episodes of care, including diagnostic tests, procedures, and medication information.  This potentially would decrease extra costs from unnecessary duplication of services as well as reducing medical errors from incomplete understanding of the patients’ illness histories and medical care provided.

It is also believed that better coordination of care may prevent 30-day hospital readmissions (which occur for nearly one in five Medicare discharges), since needed post-discharge care would be more readily obtainable with more aggressive care coordination.

Medicare patients in ACOs, however, would still be allowed to see providers outside of the ACO, and proposals exist to prevent physicians in ACOs from being penalized for patients with a greater illness severity or complexity.

According to a CMS analysis, ACOs may result in Medicare savings of up to $960 million over three years.  Although the Affordable Care Act’s ACO provisions primarily target Medicare beneficiaries, private insurers are also beginning to create care models based on the accountable care paradigm.  Insurers could offer similar incentives to the ACO model described above, and which might include features such as performance based contracting or tiered benefit models that favor physicians who score highly on care quality and cost-efficiency measures.

Balance

Only the Beginning

ACOs and other implementations of the accountable care paradigm, however, are in their beginning stages, with a number of pilots around the country currently being conducted to more fully evaluate the concept, and there still is some controversy over the best way to achieve these goals. It is a continuing balancing act.

The critical point here is that in all likelihood, with the advent of the ACA and other initiatives, stemming the upward tide of medical cost increases becomes an even higher priority, and no matter what the final models will look like, the success of any of the models requires a high level of care coordination – requiring information systems that are fully compatible and allow seamless and errorless transmission of information between sites of service and the various providers that can be involved in patient care.

More:

  1. Ground Breaking Book Explains Why Accountable Care Organizations May Be the Answer the Health Care Industry Has Been Seeking!
  2. Evaluating ACOs at Mid-Launch
  3. How Using a ‘Scorecard’ Can Smooth Your Hospital’s Transition to a Population Health-Based Reimbursement Model
  4. Doubting the Accountable Care Organization B-Model

Assessment

Thus, wherever a patient goes for care, all the information needed to provide high-quality and cost-efficient care is immediately available.

References

Feds Take Critical Look at Meaningful Use Payments”, InformationWeek Healthcare, October 24, 2012.  http://www.informationweek.com/healthcare/policy/feds-take-critical-look-at-meaningful-us/240009661 [Accessed on November 2, 2012].

Conclusion

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How affordable is the new health care law – Really?

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Calculate your costs

[By Staff Reporters]

The Affordable Care Act is going to change health care for tens of millions of Americans.

But, what about the cost?

LET’S BEGIN

ACA

###

NOW CALCULATE

Whether you’re an individual who has health insurance or needs it, or a small business owner, you need to know how health care reform affects you.

What’s it going to cost? What’s happening in your state?

### 8C9220491-tdy-130929-aca-calculator-4x3-606p_blocks_desktop_large

### 

Link: http://www.nbcnews.com/health/how-affordable-new-health-care-law-really-calculate-your-cost-8C11296290

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Affordable Care Act HIEs at Launch

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Some Important Launching Information for Doctors and Business Owners

By Bobby Whirley CPA

[Whirley & Associates LLC – Alpharetta, GA]

Dear ME-P Readers,

The ACA (Affordable Care Act) requires employers to provide their workers with a notice about the state health insurance exchanges.

Today October 1st is the deadline for providing these notices.

These exchanges will sell insurance to individuals who don’t get coverage through their employers. The exchanges are also available to medical practices and small businesses, which may or may not currently offer heath care coverage.

The Fines?

Some doctors or business owners are concerned about paying a fine of up to $100 per day under the general non-compliance penalty provisions.

The recent notice of the Affordable Health Care Act states that there will be no penalty.  Please refer to http://www.dol.gov/ebsa/faqs/faq-noticeofcoverageoptions.html

If your medical practice, clinic or company is covered by the Fair Labor Standards Act (you have one or more employees, sales of over $500,000, and deal in interstate commerce), you must provide a written notice to your employees about the Health Insurance Marketplace by Oct 1, 2013.

Model Notices

The U.S. Department of Labor has two model notices to help employers comply. There is one model for employers who do not offer a health plan and another model for employers who offer a health plan or some or all employees.

More:

The model notices are also available in Spanish and MS Word format at http://www.dol.gov/ebsa/healthreform/

###

Health-Information-Exchange

###

Assessment

Employers may use one of these models, as applicable, or a modified version. More compliance assistance information is available in a Technical Release issued by the US Department of Labor.

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The Supreme Court Permits Healthcare Taxation “Penalty”

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On the PP-ACA

By Children’s Home Society of Florida Foundation

In 2010 Congress passed the Patient Protection and Affordable Care Act (PPACA). A key part of the Act is an individual mandate for health insurance. All individuals must have health insurance by 2014 or pay a tax-penalty.

The Tax Penalty

The tax-penalty starts at the greater of $285 per family or 1% of income in 2014. However, by 2016, the tax-penalty increases to $2,085 per family or 2.5% of income, whichever is larger.

Commerce Clause

Many states sued the federal government and asked that the individual mandate be held invalid. While the various courts had different positions on the issue, some federal judges were concerned that requiring a person to purchase insurance could be a violation of the Commerce Clause of the U.S. Constitution.

CJSC John Roberts

Chief Justice of the Supreme Court John Roberts wrote the opinion for a 5-4 majority in the PPACA case. First, he determined whether or not the Court was prohibited from ruling on the case under the Anti-Injunction Act. He decided that the required payment would be a “penalty” for purposes of that Act and not a tax. Therefore, the Supreme Court could issue a ruling.

Second, Chief Justice Roberts reviewed the powers of government under the Commerce Clause. He agreed with the other four justices opposing PPACA that Congress had the right to regulate commerce, but does not have the right to regulate non-activity. Therefore, requiring individuals to purchase health insurance is not a permitted power under that provision. PPACA could not be approved under the Commerce Clause.

However, Roberts observed that it is permissible for the Court to consider the validity of PPACA under the power of the government to tax. He determined that the individual mandate to purchase insurance or pay a penalty-tax is permitted under that power. Roberts stated, “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” He carefully approved the use of the power without discussing the appropriateness of PPACA provisions.

Roberts found several reasons for permitting the taxing power. The tax-penalty will be paid when filing IRS Form 1040. As is true with other tax provisions, lower-income individuals are excluded from this tax-penalty. The tax-penalty is part of the Internal Revenue Code and will be collected by the IRS.

Dissenters

The four dissenting Justices would have determined that PPACA fails to meet the requirements of the Commerce Clause and would have invalidated the entire bill.

Editor’s Note: The taxes to pay for PPACA include a new tax on medical devices that will increase costs to individuals and healthcare providers. There also is a new 3.8% Medicare tax. It applies in 2013 to income and capital gains. If the expected post-election tax bill extends the current 15% capital gain rate, then the capital gains tax rate will be 18.8% in 2013. However, if the 15% federal capital gains tax rate is increased to 20%, then the new rate in January of 2013 will be 23.8%. The increase in capital gains rate may influence charitable gifts of appreciated property in 2013.

Conclusion

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Community Rating and Guaranteed Issue in the Individual Health Insurance Market

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[By Staff Reporters]

In this essay Dr. Anthony Lo Sasso provides empirical evidence of the adverse selection that resulted when states adopted community rating and guaranteed issue requirements in their individual health insurance markets but did not implement complementary mechanisms to keep lower risk individuals in the insurance risk pools.

Results of Adverse Selection

Such adverse selection can raise premiums, destabilize markets and even lead to market failure through the following cycle of events:

  • Community rating prohibits differential premiums based on health status, effectively lowering premiums for individuals in poorer health and increasing them for healthier individuals.
  • Guaranteed issue allows people to purchase coverage when they get sick, decreasing the need to maintain insurance coverage.
  • Healthy individuals respond by dropping coverage and entering the market only when they need coverage, thus the pool of enrollees becomes increasingly older and sicker.
  • This adverse selection pushes premiums for all remaining enrollees higher, provoking further departures by those at the healthier end of the spectrum.
  • Premiums increase again to reflect the ever-worsening risk pool of enrollees.
  • The cycles continue, further destabilizing the market and potentially leading to complete market collapse.

Assessment

Dr. Lo Sasso’s findings highlight the importance of providing effective mechanisms to protect the integrity of the risk pool in conjunction with the community rating and guaranteed issue provisions contained in the SCOTUS upheld Patient Protection and Affordable Care Act.

Link: EV-LoSassoFINAL

Conclusion

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Health Plans Under Pressure to Deliver Affordable and High Quality Care

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US Healthcare Expenditures Reaching Unsustainable Levels

[By Sam Muppalla]

Vice President: McKesson Health Solutions, Network Performance Management (NPM)

Expenditures on healthcare in the United States continue to increase and are rapidly reaching unsustainable levels. Pressures by businesses, households and the government to address these escalating costs and ensure high-quality healthcare are multiplying.

This is the first in a series of six essays that examine the challenges facing health plans and the ways that network design can unlock affordable care by aligning products, care models, and reimbursement.

Health insurance companies are faced with addressing a rapidly changing healthcare environment on multiple fronts. These changes are being driven by the goal of achieving a more affordable, higher quality healthcare system. Shifting market needs, increased regulatory initiatives, and a demand for administrative efficiency are requiring innovative approaches to unlocking affordable care. These pressures are originating from key healthcare stakeholders—employers, members and the government (Figure 1).

Employer Pressure

As the competition for the group insurance market increases, health plans need to respond to employer demands for products that deliver greater value. Delivering high value requires products which are tailored to the health of the employer’s specific population and emphasize wellness and prevention. An employer that can offer benefits and programs tailored to meet their employee needs can both improve their workforce productivity and optimize their healthcare spend. The employer’s insistence for reduction in premiums and decrease in the rate of premium growth is challenging health plans to develop more innovative strategies.

Consumer/Member Pressure

With the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA), the Congressional Budget Office (CBO) estimates (Figure 2) that approximately 32 million more individuals will require access to healthcare services. This represents a significant increase in the number of new healthcare consumers at a time when health insurance companies are required to guarantee issue and re-newability of coverage. Steering this influx of new members to the right care teams will be a very critical core competency for health plans to develop. It is one of the few risk management tools left in the plan’s arsenal in a guaranteed access world. The growth of the individual market is also being accompanied by an increase in member financial responsibility. Members are increasingly demanding greater transparency into their provider quality, performance and cost information.

Government/Regulatory Pressure

Evolving healthcare regulation puts still more pressure on health plans. New regulations within the PPACA Section 9016, stipulate an 80% MLR cap for small groups (fewer than 100 lives) and an 85% Medical Loss Ratio (MLR) cap for large groups (more than 100 lives). These regulations also cap the percentage of revenues that can be earmarked for operational and administrative expenses at 15-20%. This poses a unique challenge for health plans; it requires plans to innovate in the areas of products, care models, and reimbursement designs without increasing the administrative and operational overhead.

There are roughly eighteen additional PPACA provisions that put further pressure on health plans by promoting increased collaboration (sections: 6301, 4201, 3027, 3011, 3021, 10333, 3022, 3024) and accountability (sections: 2705, 3006 & 10301, 3001, 3025, 2706, 2704, 3023, 3004, 3008 and 3002). The Bureau of National Affairs best summarized these provisions by stating,

“The comprehensive provisions in the act regarding payment and delivery reform reflect both the payment system continuum—from fee-for-service to bonus incentives for quality to bundled payments to partial and full global payments as well as the delivery system continuum—from independent clinicians and hospitals to small group practices to multi-provider networks to partially or virtually integrated organizations to fully integrated systems with common ownership and employment.”

These demands mean that health plans need to offer new high-value products that incorporate outcome-based reimbursement to drive quality outcomes and not pay for potentially avoidable costs.

According to studies by the Robert Wood Johnson Foundation and Prometheus Payment (2009), “Up to 40 cents of every dollar spent on chronic conditions and 15 to 20 cents of every dollar spent on acute hospitalization and procedures are attributable to potentially avoidable complications (PACs).”

With evidence like this health plans are taking a new, hard look at when and how care is delivered.

Assessment

Next time, we’ll be looking at how health plans are responding to these challenges with innovations in products, care models, and reimbursement structures. Visit the blog next week for “The Three Levers of Innovation for Care Affordability.”

If you can’t wait, you can read the entire Unlocking Affordable Care by Aligning Products white paper now; it’s available on our website.

A Webinar 

On December 8th, we’ll be hosting a webinar on Lean Provider Lessons for Post Reform Success. Plan to attend this free webinar for more insights into designing for affordable high-quality care.

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Is Informatics the The Curse of Healthcare Reform?

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Medical Coding Complications and Greed

[By Darrell K. Pruitt DDS]

Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

Complications 

Complications in healthcare informatics – including 5-digit CPT® code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

Call me Cynical 

Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

CPT® Codes and Patient Care 

Accurate CPT® coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act [ACA] can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

http://www.modernhealthcare.com/article/20100623/NEWS/306209989/-1

Of Whistle-Blower Lawsuits

Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

computer-hardware1

“The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

Assessment 

What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Resource Service out of Dallas. He’s never let me down (This is not a paid ad).

Conclusion

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Has the HIT Bubble Already Popped?

Long Before Reaching … Dentistry

[By Darrell K. Pruitt DDS]

HCPlexus recently partnered with Thompson Reuters to conduct a nationwide survey of almost 3,000 physicians about their opinions of the quality of health care in the near future considering the Patient Protection and Affordable Care Act (PPACA), Electronic Medical Records, and their effects on physicians and their patients. (See “5-page Executive Summary”)

http://www.hcplexus.com/PDFs/Summary—2011-Thomson-Reuters-HCPlexus-National-P

Results:

“Sixty-five percent of respondents believe that the quality of health care in the country will deteriorate in the near term. Many cited political reasons, anger directed at insurance companies, and critiques of the reform act – some articulating the strong feelings they have regarding the negative effects they expect from the PPACA.”

What’s more, one in four physicians think eHRs will cause more harm than help. So what’s the accepted threshold for the Hippocratic Oath to come into play?

Do you also find excitement in healthcare reform’s surprises? Experiencing the sudden, last minute turns healthcare reform has taken lately is like riding shotgun with Mayhem behind the wheel, texting. Here’s other discouraging news from the same HCPlexus-Thompston Reuters survey: “A surprising 45% of all respondents indicated they did not know what an ACO is, exposing a much lower awareness of ACOs versus the broader implications of PPACA. It appears there has been a lack of physician education in this area.”

ACOs Defined 

Since I also had no idea what an ACO is, I searched the term and came across a timely article that was posted on NPR only days ago titled, “Accountable Care Organizations, Explained.”

http://www.npr.org/2011/01/18/132937232/accountable-care-organizations-explained

Author Jenny Gold writes: “ACOs are a new model for delivering health services that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs.” Does that remind anyone of insurance HMO promises just before the bad idea collided with surprisingly intelligent consumers in the early 1990s? Kelly Devers, a senior fellow at the nonprofit Urban Institute, is quoted: “Some people say ACOs are HMOs in drag,” There’s a sharp turn nobody warned us about.

HMO Differentiation 

Further blurring the difference between ACOs and HMOs, Gold adds “An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. Under the new law, ACOs would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.” I wonder if we’ll see a resurrection of HMO gag orders preventing physicians from discussing effective but expensive treatment alternatives not offered by the ACO.

As expected, not only are hospitals and doctors competing for the opportunity to run ACOs, but so are former HMO insurance agents. Devers explains, “Insurers say they can play an important role in ACOs because they track and collect data on patients, which is critical for coordinating care and reporting on the results.” As a provider, do you trust UnitedHealth’s Ingenix data mining tendencies? A few years ago, NY State Attorney General Andrew Cuomo spanked the company for selling insurers pseudo-scientific excuses to cheat out-of-network physicians.

Just like Health Maintenance Organizations don’t maintain health, insurer-based Accountable Care Organizations will not bring accountability to care any more than the Patient Protection and Affordable Care Act provides patient protection and affordable care. And since I’m exposing blatant bi-partisan deceptions, there is no privacy or accountability in the Health Insurance Portability and Accountability Act, and the “HIPAA Administrative Simplification Statute and Rules Act” doesn’t.

HITECH Funding

Gold suggests that because HITECH rules were written intentionally vague in order to push the envelope of stakeholders’ imaginations, similar to HIPAA’s ineffective security rules I suppose, the doctors’ predictable ignorance of ACOs is understandable.

But then again, all this may not even matter in a few months. According to Howard Anderson, Executive Editor of HealthcareInfoSecurity.com, HITECH funding itself is threatened. He recently posted “GOP Bill Would Gut HITECH Funding – Unobligated HITECH Act Funds Would be Eliminated.”

http://www.govinfosecurity.com/articles.php?art_id=3306

Assessment

While Obama’s healthcare reform teeters between two houses, I encourage consumers to plead with their lawmakers to stop being suckered in by cheap, meaningless buzzwords sprinkled in the titles of bills. I’m hoping we can at least get them to read a little deeper. Be on your toes. Mayhem is “recalculating.”

Conclusion

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Recognizing the Differences between Healthcare and Other Industries

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Why Hospitals, Clinics and Medical Offices are Not Hotels, or Manufacturing Plants or Production Assembly Lines, etc.

By Dr. David E. Marcinko FACFAS, MBA, CMP™

[Editor-in-Chief]

The rising cost of health insurance remains a major concern for business; despite the Affordable Care Act [ACA] of March 2010. Local and national news publications have trumpeted that healthcare costs are not just rising but are growing in proportion to the cost of other goods and services.

Many of these publications have expressed the widely held view that because of the “inflation gap,” the cost of medical expenses needs curbing.  Proponents of this viewpoint attribute the growth in the gross domestic product (GDP) devoted to personal medical services (from 5% in 1965 to approximately 14% in 2005 and 17% in 2012) to increases in both total national medical expenditures as well as prices for specific services, and then conclude that there is a need to rein in the growing costs of healthcare services for the average American, even if it be through a legislative mandate.

Healthcare Is the Economy

According to colleague Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants LLC in St. Louis, MO, healthcare cannot be separated from the economy at large. Although economists have cited the aging population as the reason for the increase in healthcare’s share of the GDP, other voices assert that financial greed among HMOs, pharmaceutical companies, hospitals, and medical providers like doctors and nurses is responsible.  In reality, the rise in healthcare expenditures is, at least in large part, the result of a much deeper economic force.

www.CertifiedMedicalPlanner.org

As economist William J. Baumol of New York University explained in a November 1993 New Republic article: “the relative increase in healthcare costs compared with the rest of the economy is inevitable and an ineradicable part of a developed economy. The attempt [to control relative costs] may be as foolhardy as it is impossible”.

Baumol’s observation is based on documented and significant differences in productivity growth between the healthcare sector of the economy and the economy as a whole.

Low Productivity Growth

Healthcare services have experienced significantly lower productivity growth rates than other industry sectors for three reasons, according to Cimasi:

1) Healthcare services are inherently resistant to automation. Innovation in the form of technological advancement has not made the same impact on healthcare productivity as it has in other industry sectors of the economy.  The manufacturing process can be carried out on an assembly line where thousands of identical (or very similar) items can be produced under the supervision of a few humans utilizing robots and statistical sampling techniques (e.g., defects per 1,000 units). The robot increases assembly line productivity by accelerating the process and reducing labor input. In medicine, most technology is still applied in a patient-by-patient manner — a labor-intensive process. Patients are cared for one at a time. Hospitals and physician offices cannot (and, most would agree, should not) try to operate as factories because patients are each unique and disease is widely variable.

2) Healthcare is local. Unlike other labor-intensive industries (e.g., shoe making), healthcare services are essentially local in nature. They cannot regularly be delivered from Mexico, India or Malaysia.  They must be provided locally by local labor.  Healthcare organizations must compete within a local community with low or no unemployment among skilled workers for high quality and higher cost labor.

3) Healthcare quality is — or is believed to be — correlated with the amount of labor expended. For example, a 30-minute office visit with a physician is perceived to be of higher quality than a 10-minute office visit. In mass production, the number of work-hours per unit is not as important a predictor of product quality as the skills and talents of a small engineering team, which may quickly produce a single design element for thousands of products (e.g., a common car chassis).

Assessment

Healthcare suffers a number of serious consequences when its productivity grows at a slower rate than other industries, the most serious being higher relative costs for healthcare services. The situation is an inevitable and ineradicable part of a developed economy.

For example, as technological advancements increase productivity in the computer, and eHR, manufacturing industry, wages for computer industry labor likewise increase. However, the total cost per computer produced actually declines.  But in healthcare (where technological advancements do not currently have the same impact on productivity), wage increases that would be consistent with other sectors of the economy yield a problem: the cost per unit of healthcare produced increases.

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The PPACA and Physician’s Ability to Bill

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Failure of Physician Referral Sources to Enroll in Medicare’s Provider Enrollment, Chain and Ownership System [PECOS] May Affect their Ability to Bill

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By Garfunkel Wild, PC

In response to, among other things, the Patient Protection and Affordable Care Act that was signed into law earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on May 5, 2010 that requires all:

  • Physicians [1] and non-physician practitioners [2] who order or refer Medicare beneficiaries for, or furnish Medicare beneficiaries with, Part B covered items and services; and
  • Physicians who certify home health services be enrolled in PECOS as of July 6, 2010 in order for the billing provider to receive payment for the ordered, referred, or furnished items or services under Medicare Part B (and, in the case of home health services, Part A).  Some of the types of claims that will be affected by this new rule include:
  • Claims from laboratories for ordered tests;
  • Claims from imaging centers for ordered imaging procedures;
  • Claims from suppliers of DMEPOS for ordered DMEPOS;
  • Certification for Part A and Part B covered home health services; and
  • Claims from specialists or specialty groups for referred services (including, but not limited to, physical therapy services).

In addition to prohibiting payment for these services, the interim final rule also requires that the teaching physician — NOT the intern or resident — be identified on the claim for Part B services as the referring or ordering physician whenever an intern or resident orders or refers.  This is also effective as of July 6, 2010.

Physician Health

Assessment Therefore, all providers who bill for ordered, referred, or furnished items or services that are payable under Medicare Part B (and home health care providers who bill for Part A and/or Part B covered services) should check the “Ordering and Referring Report” maintained by CMS to confirm whether the ordering or referring provider has an enrollment record in PECOS before submitting a claim as of July 6, 2010.

This Report can be viewed at: www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

If the ordering or referring provider is not listed on the Report, there is confusion as to whether billing providers are entitled to submit claims for items and services ordered or referred by such providers.  While CMS has acknowledged that some providers have encountered problems getting their information into PECOS and announced that, for the time being, it will not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010, CMS has expressly declined to delay implementation of the interim final rule as of the date of this Alert.

References [1] This includes a doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, and doctor of chiropractic medicine.

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Current Outlook for the Hospital Industry

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Adaptation is Key in 2010 and Going Forward

By Robert James Cimasi; MHA, ASA, AVA, CBA, CMP™

cimasi

www.HealthCapital.com

Hospitals today must continually adjust to deal with pressures to contain reimbursement and utilization levels.  The continuing cost containment pressures manifest themselves in many patients being shifted not only to lower acuity treatments but also to other providers.

Reimbursement mechanisms are increasingly designed to control costs and access. Managed care insurance plans continue to be a strong influence as payers for acute care hospital services. Medicare’s HOPPS [hospital outpatient prospective payment system] has reduced many of the financial benefits of shifting more care to outpatient settings.

Personnel Shortages

Personnel shortages have plagued the industry, and with the pending retirement of baby-boomers, relief from these shortages seems remote. This population also heavily influences the consumer side of the industry, since healthcare plans are based heavily upon demographics.  Aging baby-boomers are the fastest-growing segment of the population; the portion of the population over 65 years old is expected to increase from 20 million in 1970 to 69.4 million in 2030. Following closely behind is the increase in other minority populations.  Both groups will influence how healthcare services are dispensed.

Additionally, despite pressure to limit ALOS [average length of stay] and the shift to outpatient and freestanding, off-campus care, there will continue to be demand for acute care hospitals and the demographic trends will support this demand for many years.

Technology

Technological advances always play a central role in changing the medical industry.  The issue will be how healthcare providers will adopt new technologies under their current capital constraints.

Currently, health care insurance coverage is a major unfolding issue in the US, and there remains uncertainty about the future level of both public and private insurance coverage.  Now, facing the recent economic instability, employers are looking at restraining healthcare benefits for their employees even more as a way to stay profitable.

Assessment

The decline in the healthcare workforce coinciding with the increase in labor costs and resource consumption poses an ongoing challenge.  And yet, in the midst of the economic turmoil, hospitals must continue to provide services while remaining aware of the economic threats that may still lie ahead.

More:

Conclusion

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Reporting Tips for Covering High Risk Health Insurance Pools

A Call to all ME-P Citizen and Investigative Journalists

By Hope Rachel Hetico RN, MHA

[Managing Editor]

According to our colleagues from the Association of Health Care Journalists [AHCJ], the federal government and states are scrambling now to create temporary high-risk pools for the medically uninsurable by July 1, 2010. As one of the first provisions of the Patient Protection and Affordable Care Act to go into effect, it will serve as a test case for implementation of the new law and it should be closely followed.

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Some states with existing high risk pools are passing laws to ensure their programs comply with the new federal rules and are eligible for some of the $5 billion in federal funding. Other states are refusing to alter their programs and ceding responsibility to the federal government.

But, apart from being a policy story, it’s of great interest to all our ME-P readers, viewers or listeners who have pre-existing conditions and are struggling to find coverage. 

Avoid HI Scammers

Finally, don’t be scammed into buying fake health insurance. With unemployment high and complicated health care changes under way, scammers see big opportunities. Here’s how to avoid getting hurt. 

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/scams-peddle-fake-health-coverage.aspx

Assessment

And so, we now ask our ME-P citizen journalists or investigative reporters to cover this topic for story tips, suggestions, comments and related posts. We hope to add your insights and resources as the story develops. 

Conclusion

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