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    Dr. Marcinko is originally from Loyola University MD, Temple University in Philadelphia and the Milton S. Hershey Medical Center in PA; as well as Oglethorpe University and Emory University in Georgia, the Atlanta Hospital & Medical Center; Kellogg-Keller Graduate School of Business and Management in Chicago, and the Aachen City University Hospital, Koln-Germany. He became one of the most innovative global thought leaders in medical business entrepreneurship today by leveraging and adding value with strategies to grow revenues and EBITDA while reducing non-essential expenditures and improving dated operational in-efficiencies.

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    Dr. David E. Marcinko’s professional memberships included: ASHE, AHIMA, ACHE, ACME, ACPE, MGMA, FMMA, FPA and HIMSS. He was a MSFT Beta tester, Google Scholar, “H” Index favorite and one of LinkedIn’s “Top Cited Voices”.

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Election Impacts ACA, Medicaid Expansion and Marijuana

Healthcare Triage News: Election Results Impact the ACA, Medicaid Expansion, and Marijuana

via Aaron Carroll

The recent election results of last week have a lot of impact on health care in the United States.

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Pot House

***

The new Democratic House of Representatives and the ACA, expansion of Medicaid in red states, and medical and recreational marijuana are all affected by recent returns.

***

MORE: What The Midterm Election Results Mean for Health Care?

http://www.msn.com/en-us/news/us/what-tuesdays-midterm-election-results-mean-for-health-care/ar-BBPsC1G?li=BBnb4R7

Assessment

Your thoughts are appreciated.

MORE FOR DOCTORS:

“Business of Medical Practice 2.0” https://tinyurl.com/yb3x6wr8

“Financial Management Strategies for Hospitals” https://tinyurl.com/yagu567d

“Operational Strategies for Clinics and Hospitals” https://tinyurl.com/y9avbrq5

***

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Changes for 2017

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***

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Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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***

Racial Disparities in UnInsured Rates

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graphoid111616

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Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

***

Presidential Politics & Wall Street

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and ….. Doctors!

Rick Kahler MS CFP

By Rick Kahler MS CFP®

Recently, I reported on a survey that found most investment advisors are expecting the presidential election to result in rough seas for both their businesses and their client’s long-term retirement portfolios.

As it turns out, I am in the minority of advisors that disagree with that belief.

Presidential Power?

This is why. Even though the U.S. President is often called the most powerful person in the world, our presidents don’t run the economy any more than they run the Congress or the Supreme Court. While they may have some influence over all three, that influence goes only so far.

Certainly the president, as head of the executive branch, has authority over enforcing or not enforcing the laws passed by Congress. We’ve witnessed this most notably with President Bush, who didn’t enforce some environmental laws, and President Obama, who has vigorously enforced them. This gives the president a lot of influence on enforcing regulations which impact business and consumers.

Enforcing or not enforcing regulations dealing with commerce and Wall Street can have some influence on the economy.

Executive Branch Powers

Still, Executive Branch powers include foreign affairs, ordering military actions, and making appointments to the courts. Congress enacts all laws and controls the spending. The Supreme Court decides if both the Executive Branch and the Congress comply with the Constitution. Presidents can certainly influence Congress, but they remain one cog of many cogs in the wheel of government.

While the president has an influence on the economy, it isn’t the major influence that the media or either political party make it out to be. People think a president has great power to fix an economy. Even presidential candidates believe their own rhetoric around what they can accomplish until they take up residence in the Oval Office and discover there are a plethora of constraints that mute their power. This is how the founding fathers designed our government, which is actually a good thing, especially in this election cycle.

Long Term Portfolios

That is why, viewed in the context of your long-term retirement portfolio, you need not worry about who becomes president. Could there be some short-term swings in the stock market? Certainly.

Will who is elected president in November make a difference in the long run … No?

Of More Concern

Of slightly more concern, and potentially more economically impactful, is if one party gains control of both the Executive Branch and Congress. The last time we saw that was in 2008-2010 when the Democrats controlled both houses of Congress and the Presidency. One of the biggest outcomes of that two-year run was the passing of the Affordable Health Care Act, which certainly had a large economic impact. Whether that impact was positive or negative depended on your economic status. For many of the uninsured working poor, it was a godsend. For anyone not qualifying for a subsidy on the exchanges, it was a massive increase in health premiums.

That said, I won’t be doing anything differently with my investments even if we have a Democratic or Republican sweep of the Congress and Presidency. If you have a globally diversified portfolio of many different asset classes, you have no need to make any adjustments.

And now … Doctors and Political Parties

*** original

Your Surgeon Is Probably a Republican, Your Psychiatrist

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Assessment

While I am neutral as to the impact of the presidential election on my investment portfolio, that certainly does not mean I don’t care about the election or the person who represents our country in its highest office. I am going to vote, because elections do matter. The choices we make as voters, not only for president, but for Congress and state and local officials, do have an impact on the direction of our country.

MORE: President Trump vs. President Clinton: The impact on physicians

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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***

Sherlock Health Administration Expense Benchmarks Invitation

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Sherlock Benchmarks – Participation and Licensing

By Douglas B. Sherlock CFA

sherlock@sherlockco.com

thoughtSherlockHello All ME-P Readers and Subscribers:

This email invites your participation and/or licensing of the Sherlock Benchmarks.

A central effect of the Affordable Care Act is to sharply increase the incentive for health plans to minimize their administrative expenses. The Sherlock Benchmarks can be a catalyst to respond to these incentives since they identify and prioritize cost variances.

Use of the Sherlock Benchmarks reflects this:

• At least 40 health plans serving at least 40 million people with health insurance are so far committed as participants in this year’s Sherlock Benchmarking study.

• Of the 36 U.S. – based Blue Cross Blue Shield primary licensees, one-half are participating in this year’s Sherlock Benchmarking Study, either as an enterprise or through a subsidiary.

• Of the 13 members of the Alliance of Community Health Plans that are not focused on public programs or are staff-model plans, 11 are participating in this year’s Sherlock Benchmarking Study for Independent / Provider – Sponsored Health Plans.

• Most of the largest members of the Health Plan Alliance that are not focused on public programs are participating in this year’s Sherlock Benchmarking Study for Independent / Provider – Sponsored Health Plans.

• Health plans serving at least one-half of all insured Americans are licensed users of Sherlock Benchmarks since January 1, 2015.

Licensing and participation is available to all health plans

We have recently launched the Independent / Provider – Sponsored and Blue Cross Blue Shield surveys. There is still time, but the financial metrics survey form must be returned to us by the end of April.

So please contact me immediately if you wish to join these robust panels.

Our universes of Medicaid and Medicare plans will launch in a few months to avoid conflict with your Medicare bid process. If a plurality of your members are in either Medicare or Medicaid, please contact us about participation. Note that all costs are segmented by product as well as by function to assure an apples-to-apples comparison between the plans.

Licensing is available without participation. Licensing costs more but it entails less effort.  The 2016 Sherlock Benchmarks for Blue Cross Blue Shield Plans and Independent / Provider – Sponsored plans will be available beginning in July. The 2016 Sherlock Benchmarks for Medicare plans and Medicaid plans will be available beginning in September. 

Assessment

We look forward to working with you.

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Health Insurance Costs [circa 2016]

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The most devious tax increases in modern history? 

Rick Kahler MS CFP

By Rick Kahler MS CFP®

http://www.KahlerFinancuial.com  

A few months ago I scoffed when my wife told me about a report from CNN that the average individual, unsubsidized health insurance premium was going up over 60%.

After receiving my 2016 premium notice from Wellmark Blue Cross and Blue Shield, I’m no longer scoffing. My monthly premium for family coverage went from $1,400 to $2,140, an increase of $740, or 53%. According to healthcare.gov, the average Wellmark increase in South Dakota is 43%.

I immediately started looking for ways to decrease my premiums. This has become an annual ritual ever since Obamacare was pushed through Congress in 2010. Back then, my family health insurance policy (now considered a Platinum plan) had a low deductible with a maximum out-of-pocket of $3,500 and cost $660 a month.

Despite the President’s promise that “If you like your plan you can keep your plan,” I can’t even purchase that same plan today. If I could, I estimate it would cost over $3,500 a month. In order to keep health insurance affordable, each year I’ve reduced my coverage, increased my deductibles, and paid a higher premium than the year before.

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kidney

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I set out to analyze my options for 2016. After spending six hours crunching numbers and pouring over online calculators, I admitted defeat. There is no simple way to analyze plans to determine whether, based on your personal health care expenditures, you are better served to go with a copay or a deductible plan, a Bronze or a Silver plan, or if a Health Savings Account is preferable to a plan with coinsurance. All the online calculators I found were limited in scope and woefully generic. My health insurance agent didn’t know of any better ones, either.

Adding to my angst, while Wellmark makes policyholders’ year-to-date healthcare expenses available on its website, it doesn’t provide any breakdown of costs. You must figure out for yourself how many drug or doctor co-pays you had, the average cost of a copay visit, the average total costs of those visits, and any other information you need for any type of analysis.

This task was daunting for me, a financial planner and numbers guy. How are average consumers supposed to navigate it? The need for this information is so obvious, one wonders what the insurance companies are hiding by not providing it.

Ultimately, I selected a Bronze plan with no copays and an out-of-pocket cap of $11,900 on in-network providers and $18,500 on out-of-network providers. Based on my family’s average health care costs for the last three years, my out-of-pocket spending for premiums, covered drugs, and approved in-network medical providers will be $2,612 per month, or $31,344, in 2016. It was $11,420 in 2010. That’s an increase of 273%, or 18.3% a year.

By comparison, during the same time period medical costs only increased 16.0%, or 2.7% a year. The increase in premiums is clearly not about increasing health costs.

The $1,660 extra per month I had available to spend on consumer goods and services in 2010 is now going to insurance companies to subsidize the health care of others. This is a clear-cut example of a massive transfer of wealth.

Based on my family’s needs, if I earned $97,000 a year I would qualify for a subsidy of $912 a month. But since I earn over $98,000, I pay the full premium.

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incontinence

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Assessment

Clearly, the only people who find the Affordable Care Act affordable are those who receive a subsidy or who have preexisting conditions. For them, Obamacare was a godsend. For the rest of us, it turned out to be one of the most devious tax increases in modern history. 

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™  Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

***

Average Advance Payment of HIE Tax Credit Amounts

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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***

[HOSPITAL OPERATIONS, ORGANIZATIONAL BEHAVIOR AND FINANCIAL MANAGEMENT COMPANION TEXTBOOK SET]

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Rapid Learning Health Systems and PCMC

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Emerging Competitive Trends in Modern Healthcare Today

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imba inc

By Dr. David Edward Marcinko MBA CMP

By Hope Rachel Hetico RN MHA CMP

SOAR

dave-and-hope10Several trends are affecting the healthcare industry today. These trends are, in turn, having an impact on the financial performance of the entire healthcare ecosystem [patients, payers and providers], alike.

The ability of physicians, allied healthcare providers and the entire industry to respond to these trends is determined by the willingness to adapt, ability to re-train, and overall business flexibility. Central, of course, is the level of leadership in making the changes.

Perhaps the foremost trend, due to the PP-ACA, HSAs and Value Based Health Care, etc., is Patient Centered Medical Care [PCMC].

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1

[Rapid Learning Health System in a PCHC Model]

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Patient-Focused Healthcare

Patient-Centered, or Patient-Focused or Holistic Health Care has several names. It focuses on patient needs, attempting to humanize patient care. Patient-Centered healthcare therefore incorporates the following:

  • patient education;
  • active participation of the patient;
  • involvement of the family;
  • nutrition;
  • art; and
  • music.

These are thought to improve patient outcomes [1]. Furthermore, some think that patients will benefit from learning how to cope with healthcare processes before they enter into those processes and that this knowledge will result in better outcomes [2].

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two

[The Current Healthcare Ecosystem]

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An example of this would be classes to prepare couples for childbirth. These classes teach prospective parents the different stages of labor and strategies for dealing with the challenges associated with each stage. They cover options for pain management such as breathing and relaxation techniques and/or analgesics. The classes also provide education about clinical options such as induced labor and caesarian sections, and they cover practical issues such as what to wear and what kind of car seat to buy to transport the newborn home.

In fact, we know from personal experience that this type of education is enormously beneficial in reducing stress and improving the decision-making ability of patients who are involved in healthcare processes.

As a result of this movement, some healthcare organizations have tried to re-engineer the processes by which care is delivered in order to make it more patient focused. This is accomplished, in large part, by bringing the therapy to the patient rather than bringing the patient to the therapy.

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3

[A Life-Long Continuous Learning System]

***

For example, storing more supplies and equipment in the patient’s hospital room means that more services can be performed in the room. Obviously, this trend has significant implications for the operations management function in healthcare organizations in the areas of layout and human resources management. Supplies and equipment may be arranged differently to facilitate patient-focused care.

Considerable staffing changes and cross training may be in order, to provide this type of service. Changes in facility layout to implement patient-focused care and reduce nonproductive movement of patients and personnel should be considered, especially when a facility is contemplating expansion or renovation of facilities.

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Citations and References

[1]  See Mang, A.L. “Implementation Strategies of Patient-Focused Care.” Hospital and Health Services Administration. 40:3 (1995): 426-525; and Kremitske, D.L. and West, D.L. “Patient-Focused Primary Care: A Model.” Hospital Topics. 75:4 (1997): 22-28.

[2]  Douglass, K. “No Pain; Big Gain.” Hospitals and Health Networks. 72:20 (1998): 38-39.

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Un-Insured Adults in the USA

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State Abortion Coverage PP-ACA

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Market-Place Plans 2015

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Abortion

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The “ObamaCare Opportunity” for Financial Advisors

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Why Physicians Need Financial Advisors Now!

[By Vicki Rackner MD]

http://www.CertifiedMedicalPlanner.org

VR MDI recently attended a surgical meeting. Most conversations with my physician colleagues turned to the same singular topic: physicians’ new financial reality.

And the message is, “It hurts!”

Physicians’ Financial Plans

Financially savvy physicians execute thoughtful retirement plans. Yet, today about half of surveyed physicians are behind where they would like to be in retirement preparedness. Further, today only about half of physicians work with professional financial planners.

As a physician myself, I understand why smart physicians fail to take smart financial action. We physicians dedicate ourselves to the alleviation of pain and suffering of others. Retirement is a distant personal concern that does not cause immediate financial pain today. We put it off.

Lesson from My Dentist

Years ago my dentist recommended that I undergo a procedure to replace a filling. He explained that the filling material put in my mouth about 40 years ago tends to pull from the tooth over time and allow new cavities to form.

As much as I like my dentist, I actively avoid spending time in his dental chair. I put off the recommended filling replacement year after year. That is, of course, until I experienced vague throbbing from that tooth. I rearranged my schedule so I could tend to this small problem before it became a much bigger problem. Who wants a root canal!

For physicians retirement planning is like that proactive filling replacement. We understand that without action there will be problems down the road. However, the threat of a problem in the distant future does not propel many like myself to action today.

***

Product Details  Product Details

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The ObamaCare [PP-ACA] Opportunity for Financial Advisors

ObamaCare is the source of acute financial pain for physicians. It’s the financial toothache. Practicing physicians are looking at:

  • Higher taxes. Doctors represent 9 of the 10 highest earners in the US.
  • Rising costs of goods and services as businesses address their own higher tax bills.
  • The costs of building the infrastructure that will lead to greater healthcare efficiencies, like converting to electronic medical records, hiring new staff to address new administrative demands and aligning with new compliance requirements.
  • Lower professional fees. The 24% Medicare fee reduction that was averted this year will become reality soon. As Medicare goes, so, too, go the rest of the insurance fee schedules.
  • Decreasing patient referrals as primary care doctors sell their practices.
  • Physicians know they need to act now to avoid the financial root canal. Each physician is in the process of creating a personal ObamaCare plan.

Physicians’ Wants and Needs

As a financial advisor, you know that physicians NEED a retirement plan. Kids need to eat their broccoli, too. It’s good for them.

Physicians WANT a plan to help them achieve the personal, professional and financial goals that drew them to a career in medicine. Engaging physicians by address their ObamaCare plan is about as hard as getting kids to eat ice cream.

What This Means for You

Today physicians actively seek experts to help them create their ObamaCare plans.

Financial advisor are winning new physician clients. As Seattle Seahawks quarterback Russell Wilson asks, “Why not you?”

If you want to work with more physician clients, this is your moment! Seize it. You have a chance to join the high-performing financial advisors mining the treasures in the medical market.

Assessment

Should wish to learn more here’s a video that addresses 4 questions:

  • Why do physicians need you now?
  • What do you need to know about physicians now?
  • How do you engage physicians now?
  • How do you conduct yourself so physicians want to conduct business with you now?

About the Author

Vicki Rackner MD is an author, speaker and consultant who offers a bridge between the world of medicine and the world of business. She helps businesses acquire physician clients.

VIDEO: https://www.youtube.com/watch?v=CeCyidc4JP8&feature=player_embedded

Enter the Certified Medical Planners

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The PP-ACA [Game Changer for Health Care Financing]

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The fuel which fires the self-funded engine of employee health and welfare plans

[By William Rusteberg]

A SPECIAL ME-P REPORT

PP-ACA Taxes for 2015

Introduction

The Affordable Care Act (ACA) has had a fundamental impact on health care financing in this country. It has effectively provided added incentives for plan sponsors to consider modified self-funding arrangements for their employee health and welfare plans in lieu of fully-insured plans. The advantages of doing so are clear.

Health care costs continue to rise despite passage of the ACA. While the ACA addresses many aspects surrounding the delivery of health care, it does little or nothing to identify and offer solutions to constantly rising costs. On the contrary, many ACA provisions are driving cost up.

Plan sponsors have a choice between assuming a passive strategy with little or no control through fully-insured funding arrangements or the alternative. The alternative affords more control and less cost. It rewards innovation and creativity. It utilizes all the tools a risk manager requires as part of his trade.

More plan sponsors are turning to self-funding in response to the ACA.

Product DetailsProduct DetailsProduct Details

The Market Leading Up To the ACA

The financial and benefit advantages of self-funded health and welfare plans became evident with the passage of the Employee Retirement Income Security Act (ERISA) of 1974. Dramatic growth in self-funding occurred when ERISA preemption, clarified legal environment, rising health care costs, widespread use of risk management, the cost containment movement (Managed Care) and high interest rates were all being experienced.

Fully insured plans continued to be a large segment of the market, especially among smaller employer groups. However, a significant number larger groups remaining fully-insured moved towards minimum premium plans, or plans which were rated retrospectively on an administration cost plus basis. This approach among larger employers mirrored self-funding advantages to some degree, however the insurance companies ultimately bore the entire risk and maintained full control over plan expenses and claim costs. These types of fully-insured funding arrangements were the carrier’s response to the growing phenomenon and popularity of self-funding.

With the advent of managed care in the early 1980’s, the entire dynamics of health care delivery changed. Third party intermediaries became an important element in the health care equation.  These intermediaries performed valuable services in cost containment which initially had a positive impact on health care benefits and costs to the advantage of both the consumer and payer.

Carefully selected health care givers were aggregated into exclusive networks of preferred providers. The theory behind the scheme was valid; selected health care providers would agree to discount their usual fees for service in return for more patients. Steerage was accomplished by rewarding consumers with improved benefits when seeking care through these “preferred” providers. All worked well, with health care costs temporarily softening.

Consumers no longer had to satisfy deductibles to receive most care. Instead, co-pays as low as $10 to see a doctor became the norm. Prescription drugs benefits, now accounting for as much as 25% of a plan’s total spend in today’s market, were easily accessed by paying a small co-pay. Access to care became easier and affordable. Utilization increased.

With increased utilization, consumers began to demand more doctors and hospitals to be added to networks. Over time, just about every doctor and hospital in a given geographic area were all on networks. Competition among insurance companies hinged upon who had the broadest network. The pressure to add medical providers became intense. A seller’s market for medical providers became an established trend that continues to this day. Preferred Provider Organizations (PPO) thus gained the advantage of a seller’s market they created while end users became subject to a weakened and impotent buyer’s market.

Over time PPO’s lost their core characteristic. There was no longer any steerage. The scheme that worked so well in the beginning began to unravel. Costs increased dramatically, year after year.

Plan sponsors failed to recognize the slow progression towards failure of managed care. They continued to subscribe to the theory behind managed care based upon reliance of advice and guidance from “trusted” insurance companies, third party administrators, agents, brokers and insurance experts posing as consultants. Unfortunately, and unknown to plan sponsors, these trusted advisors maintained a vested interest in continuing the scheme. A de facto conspiracy of third party intermediaries formed. The conspiracy continues to this day. It is one of the health care industry’s best kept secrets.

No one can dispute that managed care has failed. Health care costs have continued to increase at double digits year after year, becoming unaffordable for most Americans. Plan Sponsors, concerned and desperate for answers and solutions continue to rely on advice and guidance from third party intermediaries whose vested interests is in maintaining the status quo. To more and more employers health care costs can mean the difference between profit and loss.

The perception that private enterprise has failed in reining in costs is widespread. Private and public budgets can no longer sustain the current level of spending, let alone future health care inflation.

Pointing to failure of the market to keep medical costs affordable, many looked to government for solutions.

Product DetailsProduct Details

The Affordable Care Act & The Impact on Health Care Financing

With the passage of the ACA, we find ourselves in a dynamic and somewhat unpredictable market, particularly the political dimensions as the ACA continues to evolve. However, we do know to a large degree, how the market will be affected and what plan sponsors must do to maintain affordable health care for their employees.

The ACA’s most significant impact centers upon how group medical plans will be financially structured for years to come. The ACA effectively makes fully-insured plans less attractive while providing advantages to self-funded arrangements. Carriers have come to recognize this and are moving to increase their market share. Currently the BUCA’s (Blue Cross, United HealthCare, Cigna and Aetna) administer more self-funded business than fully-insured business on their respective large group blocks of business. They are now actively expanding this funding method to the small group market.

The ACA’s universal intent is to provide government mandated means for affordable health care for all Americans. However, the ACA as it is now written does not address cost of care nor does it mandate parameters around which cost of care is to be based. Instead, the ACA mandates rigid requirements that address what insurance companies can offer in the way of benefits, as well as profit and operating margins. There is nothing in the Act that addresses what medical providers charge and what they are paid.

These far reaching rules have dramatically impacted fully-insured plans. All ACA mandates apply to these plans, whereas self-funded plans are exempt from many of them. Fully-insured plans are effectively handcuffed affording little leeway to be proactive and innovative in plan design and cost basis. Unlike self-funded plans, little can be done to control costs under fully insured plans.

An example of a reverse outcome of good intentions pertains to the Minimum Loss Ratio mandate required of all fully insured plans but exempted under self-funded plans. Fully insured large groups are required to maintain a loss ratio wherein health care claims cannot be less than 85% of premium leaving insurance companies with15% of premium to cover their costs and earn profits. However this has had a reverse effect, the opposite of which is higher costs. The greater the cost (claims), the greater the profit to the insurance company. Fifteen percent of a larger number is larger than 15% of a smaller number.

Insurance companies remaining in the fully-insured market have little or no incentive to reduce health care costs except to remain competitive in the market. With only a handful of fully-insured carriers in any given market there is less competition. Shadow pricing between competitors can very often be an effective means of maximizing insurance company profits at the expense of the plan sponsor and plan participants. A 15% operating and profit margin becomes greater when insurance rates are higher.

A good example of a constricted market can be found in San Antonio, Texas, a market we know well. There are only four major players in the fully-insured market: Blue Cross, United Healthcare, Aetna and Humana. Employer groups who continue to fully-insure will contract with one of these four carriers.

The Lower Rio Grande Valley in deep South Texas, on the other hand, has only one major carrier in the fully-insured market. Blue Cross is the dominant carrier, with occasional, cyclical and short lived forays into the Valley by Aetna and Humana..

Fully insured health insurance carriers have developed proprietary provider networks as an integral part of their insurance plans. None to our knowledge market plans that do not utilize their PPO network as part of the offering. There is an economic reason for this and it has nothing to do with lowering health care costs.

To insure continuing higher profits, health claim costs must continue to escalate. Third party intermediaries negotiate provider agreements in secrecy with both parties agreeing to non-disclose of terms, conditions and pricing to the public. It is our opinion that if you are not allowed to see a contract you are probably paying more than you should. Plan sponsors have simply become third party beneficiaries, accessing provider agreements they cannot see, examine or audit.

Fully insured group medical insurance in today’s market requires accessing proprietary, secretive PPO contracts. These contracts drive costs up each year primarily due to automatic escalator clauses. Other contract provisions include provider re-pricing fees and shared savings provisions based on egregious charge master rates no one ever pays. There are other contract provisions that guarantee continued cost increases but we will save that discussion for another day.

Self-funding provides plan sponsors a means to comply with the ACA with less restrictive mandates and lower costs. In addition, plan sponsors have the ability to design benefits that are far more flexible. They gain the freedom to choose provider reimbursement methods based on transparency, benchmarked off costs instead of phony discounts based on inflated sticker prices no one ever pays. They have the ability to eliminate expensive third party intermediaries that bring no value, They have the ability to directly contract with willing providers based on transparent benchmarking, achieving savings of 20% or more.

The ACA’s adverse impact on fully insured plans include community rating and minimum essential benefit requirements, 3:1 age band rating, pre-existing condition inclusion, and benefit expansions. All of these mandates drive cost up.

A self-funded plan is not subject to community rating nor are they required to include all ten (10) essential benefits. In addition, self-funded plans are not subject to the 3:1 rating rule and can mitigate pre-existing inclusion through selective lasers. Lasers are an underwriting technique that increases exposure/costs only when a loss occurs. If no loss occurs, there is no effective additional load to plan costs unlike fully-insured plans that load the premium costs at the beginning of the plan year, effectively passing on a cost that may or may not be necessary.

Complementing the advantages of self-funding under the ACA, ERISA preempts the state’s ability to mandate health insurance contract terms and benefits, impose premium taxes, impose underwriting constraints and mandated premiums (varies by state) and limit employee benefit plan options.

Product Details  Product Details

The Future under the ACA

Health care costs continue to escalate. Both private and public sector budgets can no longer sustain the current level of spending, let alone future health care inflation.

Over 170 million Americans are insured through employer sponsored health plans today. These employers, fearing the effects of the ACA on their bottom line, are concerned and desperate for answers and solutions to ever increasing health care costs. To more and more of them health care costs can mean the difference between profit and loss.

Acceptance to change, historically, has been slow among employers who have traditionally relied on third party intermediaries to guide them through the complicated maze of our health care system. The ACA has effectively changed that mindset among many plan sponsors.

We are seeing a movement away from managed care by some employers, and to a lesser degree, by health care providers, particularly health care professionals. Employers, for the first time, are questioning managed care contracts they cannot see but upon which their health care costs are based.

We are seeing a major shift to self-funded arrangements which enable plan sponsors to effectively manage costs through avoidance of certain ACA requirements, underwriting advantages, and pro-active risk management.

Assessment

Product Details

Although ERISA was passed into law over 35 years ago, with the advent of the ACA more plan sponsors are accepting full fiduciary responsibility to assure that plan assets are expended prudently and in the best interests of plan participants.

Conclusion

As it stands today, the ACA is the fuel which fires the self-funded engine of employee health and welfare plans, providing flexibility, control and lower costs. It is the parking brakes of fully-insured plans.

About the Author

Bill Rusteberg is a fee based insurance consultant and principal of RiskManagers.us since 1998. He has been involved in the insurance industry for over 41 years specializing in self-funded employee welfare plans. Bill has spoken nationally on continuing changes affecting our health care delivery system, most recently at the Physician Hospital of America (PHA) annual forum in 2013 and the Health Care Administrators Association (HCAA) Executive Forum in 2014. Bill walks his audience through the complicated maze of the American health care delivery system. He exposes industry secrets that drive costs by outlining specific findings not generally known to Plan Sponsors. Bill offers common sense solutions to ever increasing health care costs. Armed with the knowledge industry insiders have kept hidden for years, Plan Sponsors are, for the first time, empowered to negotiate with insurance companies, managed care organizations and other third party intermediaries from a position of strength and can better achieve cost effective health care for their employees while often improving benefits at the same time. Bill is a licensed Risk Manager, Life & Health Counselor, Property & Casualty / Life & Health Insurance agent and Surplus Lines broker in Texas. He holds reciprocal licenses in several other states.

About RiskManagers.us

RiskMangers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods

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Update on US Health Insurance Coverage

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Census Bureau 2013 Data

By http://www.MCOL.com

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PP-ACA Premium Percent Changes from 2014-2015-2017

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For the Silver Plan 

[By Kaiser Family Foundation]

Premiums for the silver insurance premium plan that is used to benchmark tax credits under the Affordable Care Act (ACA) will fall by an average .8% in 2015, according to a new study.

Meanwhile, premiums for the lowest-cost bronze option available through the ACA’s healthcare exchanges will increase by an average of 3.3%.

Silver plans were chosen by 65% of exchange enrollees in 2014, and bronze plans were chosen by about 20% of enrollees, according a report from the U.S. Department of Health and Human Services.

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kaiser_chartfinal

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Reference: http://medicaleconomics.modernmedicine.com/medical-economics/news/aca-exchanges-silver-premiums-decrease-average-8-2015

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State Uninsured Patient Rate Reductions

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Five State with Highest Percentage Change for 2013-14

By http://www.MCOL.com

uninsured

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State Requirements for Individual Market Benefit Design and Cost-Sharing

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For Health Benefits

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ACA State Requirements

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How the ACA Affects Your RXs

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On Four Large Groups of Import

By http://www.HelpRx.info

To give you a jumpstart about how the Affordable Care Act will impact you and your prescription drug coverage we’ve researched the major impacts on four large groups of people who could see the greatest impact.

Review the info-graphic below to learn about the benefits and requirements of the ACA and share it with your friends and family that still have questions about how the ACA will affect them.

***

infographic

***

Assessment

See more at: http://www.helprx.info/blog/infographics/infographic-how-the-affordable-care-act-impacts-you#sthash.6bk5zU0D.dpuf

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Regional Distribution of Un-Insured Adults in the Coverage Gap

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Due to State Decisions NOT to Expand Medicaid

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Appreciating the Highest Rates of Uninsured or Underinsured‏ Americans

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For the Five States with the Highest Percent of People Under Age 65

***

Uninsured

***

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Health Plan Rankings and Satisfaction‏

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 Top 20 Private Health Insurance Plans [HIPs]

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Can Politically-Correct Names Save Obamacare?

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Saving Electronic Health Record Interoperability?

1-darrellpruittBy D. Kellus Pruitt DDS

If HHS successfully persuades Americans to use happy names for its bad ideas, will the cheap trick save electronic health record interoperability which is critical to the success of Obamacare?

Healthcare Lexicon 

According to the government’s modernized healthcare lexicon, doctors have been demoted to “providers,” insurance companies, including Medicare/Medicaid, have been promoted to “payers,” and patients’ position in the hierarchy has diminished from “principals” to “stakeholders” – a rank on par with 3rd parties such as insurers, HHS and other unaccountable parasites.

Wall of Shame

Ominously, HHS recently changed the contentious name “Wall of Shame” to a more innocuous“ breach reporting tool,” to describe the public list of data breaches involving the medical records of more than 500 patients. It turns out that the growing list of major data breaches is unexpectedly shaming  far too many providers and payers – including Medicare/Medicaid. Imagine that!

In fact, since Americans’ growing disgust with privacy breaches threatens the very success of Obamacare, there is evidence that HHS has turned to betraying its lawful obligation to the nation by hiding breaches from those who are most vulnerable – Americans.

HIPAA Failure

The half-baked plan to shame providers who experience data breaches – perhaps through no fault of their own – is not working out like HHS had hoped. Due to HIPAA’s abysmal failure to halt data breaches, the Wall of Shame has become a national embarrassment and an obstacle to EHR adoption. I expect the public listing of major breaches to be quietly scrapped soon in favor of keeping patients in the dark concerning their risks of identity theft.

Dentistry 

In dentistry, on the other hand, common sense as well as market resistance evidently caused HHS and other stakeholders to give up trying to prohibit use of the 8 syllable “electronic dental records” in favor of the 14 syllable “electronic health records for dental practices.”

Nevertheless, holdouts (including Dissent Doe) still occasionally feel it is important to correct this dentists when I use “EDR” instead of “EHR.” You got to love ‘em.

Obama Care 

Assessment 

Transparent silliness suggests that HHS is failing in its duties. Due to lack of accountability, we can expect EHRs and EDRs to become even more expensive and more dangerous, possibly bringing an end to Obamacare.

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Eligibility for Health Insurance Coverage as of 2014

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Among the Currently Un-insured for Selected United States

By www.MCOL.com

Eligibility

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BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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American’s Personal Experience with the PP-ACA

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The Law of the Land

By www.MCOL.com

ACA

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Assessment

So, tell us your personal experi9ence with the ACA

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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Enrollment, Coverage and the PP-ACA

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For Medicaid

By www.MCOL.com

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Assessment

1. Aetna CEO: Only 11% Of ObamaCare Signups Have Been Uninsured 
2. The Individual Mandate for Health Insurance in the U.S.
3. Survey of Americans’ Preparations for Health Care in Retirement
4. Medi-Cal at a Crossroads: What Enrollees Say About the Program 
5. The Affordable Care Act: The Exchanges Go Live

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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Doctors, Sole Proprietors and ObamaCare Taxes

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On the Self-Employment Tax

By Perry D’Alessio CPA

perry-dalessio-cpaA sole proprietor is an individual business owner [medical practice] physician-executive whose business [practice] is accounted for on a separate schedule of the owner’s individual income tax return.

Typically, owners filing their business returns via the use of Schedule C of Form 1040 have the lowest level of reporting requirements and also (in general) do the poorest job of keeping good records of business activity.

There is only one level of tax for the sole proprietor. The net profit (or loss) from the Schedule C business is reported on page one of Form 1040 and is combined with all of the other income items reported to arrive at gross income.

Different from interest and dividend income, or investment income that is typically considered passive in nature, self-employment income is income considered to be generated by ones’ own actions.

Self Employment Tax

There is “Self Employment” tax to be paid on virtually all self-employment income reported in the tax return.  Many sole proprietors get into trouble because they neglect to take this tax into account when estimating their tax liability for the year and this tax is significant as noted below.

How SET Works

Self-employment tax is paid on 92.35 percent of all self-employment net profits.  This tax is the equivalent of the combination of the employer’s and employee’s Social Security tax and Medicare tax.  Social Security tax is 12.4 percent of the first $117,000 (in 2014) in net income and Medicare tax is paid 2.90 percent of net income without any upper income limit. There is also no maximum for the .9% additional Medicare tax under the PP-ACA [Obamacare] that applies when adjusted gross income exceeds $250,000 for joint filers, $200,000 for single filers, or $125,000 on married-filing-separate returns.

solo

Social Security Limit

The Social Security income limit is indexed and adjusted (upward) annually.  The sole proprietor is allowed to deduct one half of the self-employment tax against income; however, this deduction is worth far less than the actual tax.

More

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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What is Form 834?

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President Obama’s Most Important Number

[By Staff Reporters]

This is an “834 EDI transmission.”

Health Insurers sometimes call it, more simply, “an 834.” It is a technical, back-end reporting tool that consumers never see on the Federal Website. It is meant to be read by computers, not human beings. It’s the form that tells the insurer’s system who you are and what you need. And, it might be the new health-care law’s biggest problem.

Insurers report that, in some cases, 834s are coming in wrong. That’s a much more serious problem than the online traffic bottlenecks that have dominated coverage of the health-care law’s rollout.

Washington Post Article:

This is an “834 EDI transmission.” Insurers sometimes call it, more simply, “an 834.” It is a technical, back-end reporting tool that consumers never see. It is meant to be read by computers, not human beings. It’s the form that tells the insurer’s system who you are and what you need. And it might be the new health-care law’s biggest problem.

Insurers report that, in some cases, 834s are coming in wrong. That’s a much more serious problem than the online traffic bottlenecks that have dominated coverage of the health-care law’s rollout.

HIEs

What is the ANSI 834 Enrollment Implementation Format?

The 834 Transaction is the HIPAA-compliant Benefit Enrollment and Maintenance Transaction. Its purpose is to electronically transmit enrollment and dis-enrollment information.

In 2004, DHCS implemented a 4010 834 solution, however, this was implemented along with a supplemental transaction that held eligibility history.

The HIPAA 5010 version of all transactions is scheduled to be implemented on January 1st, 2012. DHCS will implement a compliant 5010 834 on this date. The current FAME file will continue to be made available for a short period of time after this date to allow plans time to transition. Once this transition period has been completed the FAME file will no longer be made available to managed care plans.

Impacted Covered Entities

Internal DHCS program areas and DHCS Health Plan trading partners.

Links:

5010 834 Documents

General FAME Documents

MEDICARE PART D INFORMATION

Project Information

DHCS Medicare Part D information web page

MMA Part D Carrier Cross Reference Table (pdf)

File Layouts

MMEF 2100 Medicare Part D layout (pdf)

MMEF REC Medicare Part D layout (pdf)

Assessment

best-diagram

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Take the Accountable Care Organization 2013 e-Poll

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TAKE THE POLL

www.MCOL.com and Accountable Care News are conducting the 2013 Accountable Care e-Poll. Please respond by 5 PM Pacific, Friday December 13th, 2013. Results will be emailed to participating respondents upon request.

e-Poll

You can take the e-poll by going to: http://aco2013.questionpro.com/
The e-poll asks the following questions:

  1.  Please indicate your perspective:
  2. Is your organization involved with ACOs- including development, operation, or contracting arrangements?
  3. When would you estimate ACOs would have a material impact in your marketplace:
  4. If ACO Medicare pilots are not ultimately successful, will that cause commercial and Medicaid ACO arrangements to generally fail as well?
  5. What will be the impact of the newly enrolled individuals coming into the system as a result of Medicaid expansion and the health insurance exchanges?
  6. How confident are you that ACOs will actually generate the necessary savings?
  7. Will bundled payments prove to be a more effective delivery and payment reform model than ACOs?

Advocacy

Assessment

Again, to take the e-poll now, go to: http://aco2013.questionpro.com/

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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On Healthcare.Gov System Availability

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A Review of Website “Uptime”

By www.MCOL.com

HG

Conclusion

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How You Can Financially Profit from the PP-ACA?

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An Obamacare Sales Opportunity

By Dr. David Edward Marcinko MBA CMP™

[Editor-in-Chief] www.CertifiedMedicalPlanner.org

Dr. MarcinkoPresumably, as a result of my financial advisory activities, I received this email solicitation the other day,

So, I thought I’d pass it along [unchanged] to our ME-P readers, FAs, insurance agents and subscribers for comment.

USA BENEFITS GROUP EAGLE DIVISION  ………. PROVIDING CAREER SOLUTIONS FOR 36 YEARS 

[Better Contracts + Better Schedule + Better Career Opportunities] 

Dear Prospect [that would be ME],

I received your resume on Monster.  You already know that the real money in any organization is in sales. The salespeople of the world make things happen and are highly rewarded for that work.  But it’s hard work.

The Product

What if you could find a product that everybody needs, that they have money budgeted to purchase, and are looking for someone to help them buy it?  Do you think you could help that person? That’s exactly  the situation in the health insurance industry today!

Our government is telling people they HAVE to have it.  Folks are either buying it now from somewhere or will soon be eligible for subsidies so they CAN buy it.  And EVERYONE is confused and looking for someone with answers on how to get this product!

You can be that Person

Over the next sixty months, billions of dollars are going to change hands as people readjust to a dynamic health care environment.  How can you get into the river and get your hands on some of that money?  By preparing to serve people!

USA Benefits Group 

The USA Benefits Group is a highly successful team of insurance brokers who are “reform ready” – staying up to date on this perhaps once-in-a-lifetime shift in this industry.  We are independent, non-captive agents who are setting up qualified, turn-key “private exchanges” to help people obtain health insurance in a webinar-based setting from our home offices.

I’m encouraging you to click here: www.usabg.net/dcollins to learn more. If you’re serious and ready to make a move, you can call me toll-free now at 866-328-6182. If you’re qualified, I also have Regional Management positions available.

Advantages of working with my Eagle Division 

  1. 1. 36 year old system for success
  2. 2. 100% control of your future
  3. 3. Equal opportunity
  4. 4. Recession proof
  5. 5. Top Companies to represent
  6. 6. Excellent co-op lead program
  7. 7. Weekly advance commissions ($2,000 To $4,000 Net Weekly)
  8. 8. Vested Lifetime Renewals ($10,000 To $20,000 Monthly In Under 3 Years)
  9. 9. Annual Incentive Trips
  10. 10. Annual Production Bonuses to $50,000+

I’m looking forward to talking to you.
David Collins
DIVISION MANAGER
866.328.6182
DC@usabg.net

Assessment

  • Is this a good product to sell? If so, why does it need an intermediary to push it?
  • Don’t subsidies, carve-outs, exemptions and sales commissions serve to jack-up price and lower quality? [think eMRs]? What about the overall cost of healthcare delivery; up or down?
  • What about the USA Benefits Group; credible or not? Are cold calls the way to go?
  • What is your impression of Division Manager Mr. David Collins and his Eagle Division? Feel free to contact him … and tell him what you think.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
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Is HEALTHCARE.GOV Fundamentally Flawed?

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You Decide

By Ayo Fathiah

Hello Dr. David Edward Marcinko,

My name is Ayo, I’m the mother of two beautiful kids and one of the Americans that was relying on healthcare.gov to provide me with a reasonably priced health insurance.

I came across your ME-P articles when researching what exactly has gone wrong with the website. I was one of the millions that tried to sign up during the first days after the launch and couldn’t get through due to a bunch of errors. While I’m still trying to find the best insurance for my family, I just wanted to share with you some stats showing why the website was a major flop.

***

interface

***

And, I thought it might be interesting to your readers, because I saw a many readers talking about it. Isn’t it surprising that less than 1% of people that went on the website signed up for an insurance?

HCdotGOV_final

The Website

1.) Had extremely low login success rates. 2.) Long delays and time outs 3.) Confusing Error Messages 4.) Non-functional calculators 5.) Scrambled insurance information 6.) Spouses reported as children 7.) Plan pricing misreported.

Assessment

Leading to the larger questions:

  • Will enrollment glitches become provider glitches?
  • Will people who enrolled with the glitchy show up at hospitals with no insurance?
  • Will the information of those who enrolled be at risk?

DANGER: Centralized data SSN Address Ages Names Health conditions Family History

Leads to centralized power over everyday Americans

Good: if we can make an efficient healthcare system

Bad: Governmental Abuse, and all the data an identity thief could want

But this problem runs deeper than just a website… Because the numbers just don’t add up.

Universal healthcare is important, but crony capitalism doesn’t solve anything.

Citations:

  1. http://msnbcmedia.msn.com/i/MSNBC/Sections/A_Politics/_Today_Stories_Teases/Late_October_NBC_WSJ.pdf
  2. https://blog.compete.com/2013/10/15/obamacare-enrollment-stats/
  3. http://www.nextgov.com/health/2013/10/less-1-percent-healthcaregov-visitors-successfully-enrolled-insurance-plan/72041/

Conclusion

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The PP-ACA from Medicine to Dentistry

Obamacare and Dentistry

[By D. Kellus Pruitt DDS]

1-darrellpruitt It seems that problems with the PP-ACA have migrated from traditional medicine to the world of dentistry.

“MaineCare dentists hit with massive fines for minor clerical errors, they say – Some clinics face more than $200,000 in penalties under a new audit system that threatens to wipe out services for kids.”

-Joe Lawlor [Staff writer] Portland Press Herald [November 6, 2013]

http://www.pressherald.com/news/MaineCare_dentists_hit_with_massive_fines_for_minor_clerical_errors__they_say_.html

 “The new system gives auditors, who work for a private contractor, financial incentives to find small errors by paying them more for each mistake they discover.” Maine adopted the auditing system to comply with the federal Affordable Care Act, otherwise known as Obamacare.

 Lawlor continues: “The audits are intended to root out fraud and abuse, but dentists told the Portland Press Herald that auditors are finding typographical or clerical errors that do not compromise patients’ care or defraud the government.”

A Clawback?

Dr. Michael Dowling, co-owner of Falmouth Pediatric Dentistry, tells the Herald, “This is not finding fraud and abuse. This is a clawback. They (state officials) are trying to take back money that we billed them legitimately.”

Still want to help the poor so much that you are willing to take your chances with the ACA auditing system, Doc?

Dentists facing bankruptcy

According to Lawlor, some dentists are actually facing bankruptcy because of ridiculously expensive fines over minor errors. Other Maine dentists who are otherwise willing to work for charity-level fees in order to help children who have nowhere else to turn, are dropping out of MaineCare. President Obama’s plan to use outrageous fines to fund the state and federal coffers, as well as the bonuses of ambitious auditors, is destined to fail.

How can the Affordable Care Act [PP-ACA] possibly make care more affordable for children with toothaches, if it runs off all the dentists?

Mobile-Security

Assessment

Is it beginning to look to you like Obamacare might have been designed to serve the interests of unaccountable healthcare stakeholders rather than the interests of doctors and patients – the healthcare principals? Why do we put up with this crap, Doc?

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

Conclusion

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Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

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Understanding Basics of the Health Insurance Exchanges [HIEs]

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The Four Basic Categories of the PP-ACA

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

Rick Kahler CFPThe opening date was yesterday, October 1, 2013. And today, the competition is lined-up and ready to go after bronze, silver, gold, and even platinum.

These competitors aren’t athletes, but insurance providers. The field they are entering is the new health insurance exchanges [HIEs] as mandated by Obamacare [ACA].

The New Year

Beginning January 1st 2014, nearly everyone in the US will need to have health insurance or pay a tax penalty. Those not insured through their employers can apply for coverage through these health insurance exchanges, also called “marketplaces.” Enrollment began October 1st, 2013 for coverage starting in January, 2014.

These exchanges are intended to make it easier to find insurance providers and compare their coverage and costs. Each state’s exchange website will list all the policies available in that state, with prices and policy provisions.

So far, over half of the states (including my State of South Dakota) have opted to use exchanges managed by the federal government instead of setting up their own.

The Four Basic [Colors] Categories

Bronze, silver, gold, and platinum describe the four basic categories of policies that will be available through the exchanges at different costs. Here is a very brief summary of each category.

Bronze

The least expensive option is a bronze plan, which might be the best choice for younger people with lower incomes and good health. The plan will pay 60% of health care costs and the insured will be responsible for 40%.

Silver

The second level, silver, will pay 70% of health care costs.

Gold and Platinum

Gold covers 80%, and a platinum plan covers 90%. Obviously, the categories with higher benefits also will have higher premiums.

The Essential Benefits

All these plans are required to cover “essential health benefits.” These include preventive and wellness care like cancer screening, chronic disease management, pediatric care, many prescription drugs, injury rehabilitation, mental health and addiction treatment, maternity and newborn care, hospitalization, and emergency services.

Companies are not allowed to deny coverage or charge more for those with pre-existing conditions. There are no lifetime benefit limits.

The Carrot and Stick Approach

The requirement to have health insurance coverage, the “stick” of Obamacare, is accompanied by a “carrot” in the form of federal subsidies to help pay insurance premiums. It’s estimated that two-thirds of Americans will be eligible for subsidies, which will be figured on a sliding scale. The upper limit for qualifying is four times the federal poverty level, which amounts to about $88,000 a year for a family of four.

Other Outlines

This ME-P summary is just the barest outline of the health care changes coming our way. To find out more, it’s a good idea to spend some time online, especially at two sites that offer a lot of helpful information.

  1. The First site is the federal government website at www.HealthCare.gov. It provides links to the state exchanges, plus detailed information that for the most part is explained in straightforward, plain English.
  2. The Second site is the Henry J. Kaiser Family Foundation at kff.org. An especially useful tool available here (http://kff.org/interactive/subsidy-calculator/) is a calculator to determine the federal subsidy that applies at your family’s income level.

Obamacare 2014

The elements of Obamacare that take effect in 2014 represent a huge shift in the way we cover health care costs. I strongly recommend that you start now to figure out what this will mean for you and your family.

###

Obama Care

###

Don’t wait until December and end up making hasty decisions in a last-minute rush. The more informed you are; the better insurance choices you can make.

Assessment

The changeover to the new insurance environment is likely to be chaotic and confusing. Navigating it will take some energy, commitment, and stamina. When all the scrambling is over, we can only hope the ultimate winners will be the American people.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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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 status of African American insurance coverage

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A Struggling PP-ACA Sector    

By FinancesOnline.com

The Affordable Care Act has developed into one of the critical pivots on which the success of President Obama’s second term is expected to turn. Yet, one sector that’s already struggling is African Americans.

In 2012, 17.4 percent of non-Hispanic African Americans were uninsured. More critically, only 55.9 percent of African Americans are expected to continue to live in good health, while a more or less healthy life is expected in 69.4 percen of white Americans.

###

infographic-health-insurance-of-african-americans

###

Assessment

These and other alarming facts were revealed by the National Health Interview Survey of the Center for Disease Control and Prevention, and corroborated by data from the U.S. Census Bureau. Both these agencies were data sources for this infographic, which takes a closer look at the health insurance situation of African Americans.

Conclusion

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How the Affordable Care Act Affects Taxpayers Now? [Audio-Link]

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Sound Medicine –  How does the Affordable Care Act affect taxpayers now?

By Ann Miller RN MHA

Sound Medicine is a radio show produced by the Indiana University School of Medicine and WFYI Public Radio.

In the last few years Aaron Carroll MS MD associate professor of pediatrics at the Indiana University School of Medicine, has been their go-to guy on health policy.

Audio Link

So, for those of you who would find your day brightened by the sound of his voice, enjoy the following from www.theIncidentalEconomist.com

Assessment

Dr. Carroll discusses how the Affordable Care Act will affect taxpayers in the coming months. The Affordable Care Act officially takes effect in January 2014, but several provisions are being implemented this year. These provisions specifically affect Medicare and Medicaid recipients, caregivers and all taxpayers.

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Spending for Private Health Insurance in the United States

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Health Costs Doubled in the Past Decade

By NIHCM Foundation www.NIHCM.org

The total cost of health care for a typical family with employer-sponsored coverage has more than doubled in the past decade to nearly $21,000 per year, outpacing both inflation and income growth.

Skyrocketing health care costs are already straining budgets and could jeopardize the availability of affordable coverage under the ACA. To shed light on the factors behind increased spending on private insurance, this brief examines

  • trends in premiums and cost-sharing in the group and non-group markets,
  • how premium dollars are spent by insurers,
  • which sectors are driving premiums upward, and
  • the importance of price increases in explaining spending growth.

healthcare costs

Assessment

Read more…

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Understanding the House Democrats’ Health Plan [PP-ACA]

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An Organization Chart

By Staff Reporters

If you have ever wondered exactly how health care reform will work for the United States, there is unfortunately no easy answer.

But, with the democrats and republicans strongly divided on universal health care, it can be tough for the average American citizen to find answers.

Fortunately, the graphic below will help.

PP-ACA

Assessment

However, it is important to listen to both sides to make a well-rounded decision of whether or not you can get behind health care reform.

Conclusion

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Update on Health Information Exchanges [HIEs]

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A Snapshot as Deadlines Approach

http://www.MCOL.com

The federal health law [PP-ACA] gives states the option of creating health insurance exchanges [HIEs] through which residents can purchase coverage.

Now, with a November 16 deadline for states to declare their readiness to build an exchange, most states are expected to let the feds take over by default–only 15 states, and the District of Columbia, have created a health insurance exchange thus far.

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How Health Reform Could Expand Medicaid

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PP-ACA Results State-by-State

By Lena Groeger
ProPublica

Experts estimate that nearly 16 million Americans could be added to the Medicaid rolls by 2019 under an expansion in the Affordable Care Act. But, the Supreme Court ruled last Thursday that states can opt out without risk of losing federal support for Medicaid, raising the stakes that some may do so.

The Big Picture

Here is a look at forecast growth in state Medicaid rolls under the expansion. Twenty-six challenged the act in court.

IMAGE LINK: http://www.propublica.org/special/state-by-state-how-health-reform-could-expand-medicaid

Related: Mystery After the Health Care Ruling: Which States Will Refuse Medicaid Expansion?

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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.

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UPHELD

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The Increased Competition of Ambulatory Surgery Centers (ASCs) to US Hospitals

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The Competition Heats Up!

By Dr. David Edward Marcinko MBA CMP™

www.CertifiedMedicalPlanner.org

[Editor-in-Chief]

Over the last 10 years, Ambulatory Surgery Centers’ (ASCs) footprints have increased dramatically.

As hospitals and health systems accelerate towards population health/ global payment models, such as Accountable Care Organizations (ACOs), lower priced ASCs will become more critical competitors to hospitals.

Assessment

I acquired the Certificate-of-Need [CON], co-founded and operated an ASC for 15 years before sale in 2000 to a public company. My local hospital fought me tooth and nail. I likely would not do so, again, today!

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Anatomy of Health Insurance

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An Overview

Health insurance is a hotly debated topic in this year’s presidential elections. Obama-care has some doctors and citizens fuming over the possibility of universal healthcare. But, before preaching, one should get a full grasp of what health insurance entails for a typical buyer.

This infographic gives an overview of how the health insurance industry works. One thing for sure, the health insurance industry is a booming business, as the typical 22-year old will pay $400,000 for health care and insurance in his or her lifetime.

Assessment

So study up with our handbooks, textbooks, dictionaries and this ME-P so you can responsibly select an insurance plan that is right for you.

Conclusion

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Pre-Reform Impact of Self-Pay Patients on US Hospitals

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Pre-healthcare reform, and full PP-ACA implementation, many hospitals experience significant uncompensated care costs from self-pay patients.  This infographic illustrates the variation in self-pay uncompensated care costs across US hospitals and regions.

Despite the uncompensated care risk, 1/6th of self-pay inpatients are scheduled admissions, though their procedures are much less elective than the procedures of the insured.

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The Best, Most Revealing Reporting on Our Healthcare System

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Reading and Reviewing

By Blair Hickman and Cora Currier

ProPublica,  March 30, 2012, 1:44 pm

As we wait for the Supreme Court to issue its verdict on the health-care reform law  we rounded up some of the most revealing reporting on the issues.

They’re grouped roughly into articles on high costs and those on insurance.

Assesment

Link: http://www.propublica.org/article/top-muckreads-the-best-most-revealing-reporting-on-our-healthcare-system

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Hospitals & Healthcare Organizations: Management Strategies, Operational Techniques, Tools, Templates and Case Studies

Hospitals & Healthcare Organizations: Management Strategies, Operational Techniques, Tools, Templates and Case Studies

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Dire Emails About New Medicare Surtax Have It Wrong

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Enter the Obama Care Fear Mongers

By Rick Kahler MS, CFP®, ChFC, CCIM

www.KahlerFinancial.com

Ronald Reagan was noted for saying, “Trust but verify.” And, that was before Al Gore invented the Internet. When it comes to believing forwarded emails with dire warnings, it’s a good idea to go even further and “Verify before trusting.”

My e-mail

Here are a few lines from an email I’ve received numerous times over the past two years: “Did you know that if you sell your house after 2012 you will pay a 3.8% sales tax on it? That’s $3,800 on a $100,000 home . . . It’s in the health care bill and goes into effect in 2013. . . . Under the new health care bill all real estate transactions will be subject to a 3.8% Sales Tax. If you sell a $400,000 home, there will be a $15,200 tax.”

Before trusting this, I verified it with Paul Thorstenson, an accountant with Ketel Thorstenson in Rapid City, South Dakota. He said, “The information in this email is nearly entirely false.”

As with a lot of what you read on the Internet and hear from politicians, if you sift through the rubbish in this statement you will find a few grains of truth.

The True, and Not So True, Grains

First the truth

There is a 3.8% Medicare surtax contained in the health care act passed by Congress and signed into law by President Obama in 2009. It does take effect in 2013.

Now the falsehoods

This is not a sales tax. Sales taxes apply to the gross sale price of an item. Thorstenson explained this is a surtax that only applies to a gain (not the sales price) on sale of an investment asset. This not only includes real estate, but other investments like stocks, bonds, mutual funds, commodities, precious metals, and collectables. The surtax will also apply to other passive and investment income, such as interest, dividends, and net rental income.

The act only applies the surtax to investment gains when the total adjusted gross income on a return exceeds $250,000 for couples and $200,000 for single taxpayers. If your adjusted gross income is less than those amounts, the surtax will not apply.

If you sell a primary residence, the surtax will not apply to the first $500,000 of gain for couples or the first $250,000 of gain for individuals (IRS Code Section 121). “The surtax will only apply if the gain is above $500,000,” explained Thorstenson, who added, “And who even has a gain in a home these days, let alone over $500,000?”

Section 121

What is important to note is there is no Section 121 exclusion on the gains of vacation homes, second homes, or rental property. So if your adjusted gross income tips over $200,000 for individuals and $250,000 for couples in the year you sell an investment like a mutual fund, rental property, second home, or small business, you will be hit with a 3.8% tax on the portion that exceeds the $200/$250 threshold.

Assessment

Now consider what happens if President Obama gets his way and raises the capital gains tax to 28% on taxpayers earning over the $200/$250 limits. You could easily see the capital gains rate more than double from 15% to 31.8%. On every $100,000 of gain, that means a tax increase from $15,000 to $31,800.

Thorstenson told me, “This law is an atrocity in my opinion. It is an attack on successful investors, and the tax revenues aren’t even earmarked for Medicare. The proceeds just go into the general fund.”

The truth about this surtax is bad enough without believing exaggerations about it. The next time this particular email shows up in your inbox, just delete it. Trust me; I verified.

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Healthcare Reform Thru 2018

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An Evolving System

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What’s at Stake in the Supreme Court’s Health Care Decisions?

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On the PP-ACA

By Lena Groeger ProPublica

Yesterday, the Supreme Court began hearing arguments on the health care reform law. So, in this essay, we made a map of the possible outcomes following the Court’s schedule over the next three days.

The Court will hear all three days of arguments, even if they eventually decide not to decide the bulk of the case, and is unlikely to issue a decision on the case until late June or early July.

Assessment

Link: http://www.propublica.org/special/mapping-the-supreme-courts-health-care-arguments

For more information on different states’ progress implementing health care reforms, see this comprehensive list.

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