Sep
21

The most ridiculous thing I ever heard.

You Bet Your Life was a 1940’s radio quiz show featuring comedian Groucho Marx; contestants vied for prizes and cash.

If you or your family members have pre-existing medical conditions, the election is a reprise of the show – Republicans want to end coverage for pre-ex, and Democrats will keep that coverage in place.

If the Trump Administration’s Texas lawsuit backed by Republican Attorneys General succeeds, you can lose coverage for pre-existing conditions if you change healthplans, switch jobs, move, marry, divorce, or have a child. If Trump and Republicans win the case in Texas;

Briefly, Republican Attorneys General have sued to overturn the ACA, and the Trump Administration is aggressively supporting the suit.  The Trump Administration and AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by the Republican Congress in 2017.

In so doing, it would end protections for those with pre-existing conditions.

Make no mistake, if Trump et al win the suit and you have to change health insurance plans, you are at real risk of losing coverage  – or having to pay so much you can’t afford it.

Despite President Trump’s assertions, there is No Republican plan to assure those with hypertension, diabetes, a history of heart disease, cancer, anxiety disorder, or any other health condition will be able to afford health insurance.

If you just won lotto, you’re all set. If not, you’re screwed.

Ignore Trump’s claims that there is a replacement plan in the works because:

What they do have is bait-and-switch.

As Groucho would say about the Republican claim they’ll cover your pre-ex;

What does this mean for you?

If you or a family member have a pre-existing condition, this election is about you.

If you aren’t sure, here’s a list.

And if you think you can hide your condition, you can’t. 


Sep
9

The Biden Healthcare plan explained – briefly

Healthcare will be the most significant near-term impact of this election.

If Joe Biden wins and the Dems take the Senate, here’s what we can expect.

Biden’s healthcare plan addresses the biggest problems with the ACA (known to some as Obamacare).

  1. Individual health insurance plans are way too expensive.
  2. About a third of all states didn’t expand Medicaid
  3. The big insurers have little competition.
  4. Medicare – and Medicare recipients – are paying far too much for drugs

Briefly, the Biden Plan would:

  • Cap individual health insurance premiums at 8.5% of income
  • Set up a public option like Medicare anyone could buy into
  • Allow 60-65 year olds to buy into Medicare
  • Have Medicare negotiate drug prices with manufacturers
  • Solve the Medicaid expansion problem by covering low-income folks in non-expansion states through a Federal program
  • Ban surprise medical billing for insureds that require out of network hospital care
  • Ensure pre-existing conditions are covered

The additional costs would be paid for in part by savings (e.g. drug costs) and abolishing the capital gains tax break for those making more than a million dollars a year. (More detail on this plan, along with pros and cons – is here.)

Does this solve the ACA’s problems?

It’s not a cure-all, but Biden’s plan does go a long way to fixing the ACA’s two biggest problems – healthcare is still unaffordable and prices are still too high.

For most families covered under the plan, healthcare costs would likely decrease significantly. The 8.5% cap on insurance costs is a major change as insurance premiums in many areas are north of $12,000 a year.

Healthcare providers would:

  • Scream if folks now covered by private insurers switched to a Medicare-type program as reimbursement would drop;
  • Cheer if a lot more patients had health insurance; hospitals’ indigent care costs are escalating rapidly

The real problem with healthcare costs in the US is our prices for services are way too high. Covering a lot more Americans thru a government plan would force facilities and providers to get a lot more efficient.

Over the last six years I’ve done many a deep dive into the ACA’s shortcomings and why they exist; posts are here.

Bob Laszewski penned a very good piece on the plan here. Well worth a read.


Aug
14

Are health insurers profiting while providers suffer?

Well, yes – but it’s not intentional.

Most medical practices have seen a sharp drop in patient visits – and revenues – due to patient concern over COVID19 exposure. Hospitals have also suffered, as have ancillary providers, and many are on the brink of financial collapse.

Rural and safety-net providers are especially vulnerable, as many were on very shaky ground before COVID19.

Primary care providers are in the worst shape, as their patients often don’t have serious health needs that need to be addressed immediately. And primary care providers have the lowest pay as well. Research indicates that PCPs will lose about $15 billion this year.

Meanwhile, health insurers’ finances have never been better.

The connection is clear – insured people are not getting care, so insurers don’t have to pay their bills.

For months, healthcare providers have called on insurers to help them out by prepaying for care, paying billed charges, authorizing all treatment requests, providing loans, or otherwise funding providers. Much of this is nonsensical; authorizing all treatment requests would certainly lead to widespread abuse, over-treatment, and poor outcomes. Paying billed charges is nuts; NO ONE pays billed charges, which can be 10-30 times higher than average reimbursement.

What’s clear is COVID has likely created a significant one-time profit bump for healthplans, as a lot of foregone care will not be “made up” as practices gradually return to normal. While insurers should carefully assess their reserves, it is highly likely their “excess profits” won’t all be needed to pay for future COVID19 costs.

So, what to do?

Prepaying care may be a viable option. Healthplans would mine their data to determine what they paid a practice in the recent past, figure out how many members are using that practice, and sign a contract with the practice to ensure the plan’s interests are protected.

That’s just a short-term solution to a problem with roots that far predate the pandemic.

Reality is primary care is still under-valued, fee for service creates huge administrative friction and incentivizes over-treatment, and health care prices are unsustainably high.

What does this mean for you?

COVID will accelerate systemic changes that are desperately needed. There will be lots of pain for some stakeholders – primarily specialists and facilities.


May
22

Hey legislators…don’t do stupid stuff

Four months into the COVID pandemic, early data show workers’ comp insurers are doing the right thing.

Two data sources support this assertion – CWCI’s just-released analysis of 1,077 California claims and a dozen conversations I’ve had with insurers, large self-insured employers, and service providers over the last two days.

First, CWCI.

CWCI’s researchers and statisticians analyzed 1,077 COVID-19 claims from 28 insurer and self-insured CWCI members. Notably, these are claims filed before April 30, a week before the governor’s Order granted the disputable presumption.

Key findings:

  • Only 35% of the COVID-19 claims were denied
  • 7 out of 10 workers whose claims were denied tested negative for the virus
  • Other denials were due to:
    • the employee had not been exposed at work,
    • no diagnosis or symptoms of COVID-19,
    • the employee had been working at home, or
    • refused to take a COVID-19 test.

Next, I’m in the midst of a second national survey of payers and service providers about their experience with COVID-19. (details on the first survey are here.)

Key preliminary findings (based on a dozen completed surveys):

  • most payers have developed COVID-specific intake processes, trained staff to handle COVID claims, and set specific policies and procedures to address COVID.
  • so far, payers have accepted about 15% of COVID-19 claims
  • the range is about 10% to 25% of COVID claims filed
  • where possible, insurers surveyed are “paying without prejudice” on claims filed but not yet accepted or denied. That is, insurers are paying medical bills even if they don’t know if the patient has COVID-19.
  • Several very large self-insured employers are providing two weeks’ leave with pay to workers who fear they’ve been exposed at work, regardless of test results

What we know so far.

  1. Some percentage of filed claims are still under review, so the acceptance rate will increase.
  2. Employees who think they may have been exposed at work are filing claims, even if they are asymptomatic.

Based on what we know today, workers’ comp insurers, state funds, and self-insured employers are doing the right thing.

Despite that, several states are contemplating bills or executive action to make workers’ comp the default payer for COVID19.

California’s SB1159 is the poster child; from CWCI – “By including all types of employment without regard to the level of risk actually posted, the presumptions greatly expand the nature and scope traditionally encompassed by presumptions of compensability in California.

More specifically, the bill makes workers’ comp responsible for COVID-19 diagnoses even among workers deemed “low risk” for contracting the disease at work by OSHA. That is, workers with “minimal occupational contact with co-workers or the public.”

COVID-19 is a relatively small occupational issue, but a huge societal one.

Yes, workers who contract the disease through work should be covered by workers’ comp – and all the evidence to date indicates that’s happening.

But work comp should NOT be the piggy bank for any and all COVID claims – which is precisely what SB1159 and similar actions in other states would do.

What’s driving this is our totally dysfunctional healthcare system, one that relies on private insurers, employers, and employees to generate much of the revenue and all of the profits. Hospitals, health systems, medical practices and other providers are in desperate financial shape; it will get worse over the next few months.

Dumping the responsibility for a societal pandemic on a tiny industry that pays less than 1 percent of total US medical costs is not only irresponsible, it also won’t work. Workers’ comp insurers, excess insurers, employers, and governmental entities don’t have the financial resources, skills, staff, or capability to manage and pay for the care of hundreds of thousands of patients, while also covering their lost wages.

This is society’s problem. It’s time governors, state legislators, Congress and the President do their job. Take responsibility – just like the workers’ comp industry has.

What does this mean for you?

Workers’ comp payers – keep doing what you’re doing.

 


May
7

Watch those facility costs…

As the coronavirus continues its relentless march, hospitals and health systems are getting crushed. With elective procedures banned in many states, the profitable patients hospitals relied on to generate profits have disappeared. Meanwhile, expenses related to preparing for COVID19 patients have gone thru the roof and so no signs of abating.

Florida is especially hard hit:

A new report by the national consulting firm Crowe shows Florida health systems have suffered nearly a 50% drop in patient volume in March and April.

Hospital owner UHS just withdrew its financial guidance, with management citing concern over the “financial uncertainty caused by the coronavirus disease.” The announcement followed similar moves by  hospital giant HCA, and Maryland’s hospitals are projecting a billion dollar revenue shortfall for the second quarter. Hospitals in Colorado are facing an even larger reduction in revenues and Michigan hospitals are laying off workers, 

“Patient volumes at our acute care hospitals and our behavioral health care facilities were significantly reduced during the second half of March as various COVID-19 policies were implemented by our facilities and federal and state governments. These significant reductions to patient volumes experienced at our facilities have continued into April, 2020.”

The billions sent to hospitals under the CARES Act is no panacea; on average the funds cover less than a week’s revenue.

Implications

More than a dozen rural hospitals  in the South closed last year.  We can expect more in 2020.

Hospitals and healthcare systems are drastically ramping up their “revenue maximization” efforts. Workers’ comp payers, long seen as hugely profitable, now have an even bigger and brighter target on their chests.

What does this mean for you?

Watch those facility costs. 

 


Apr
30

COVID catch-up

In  less than 4 months, COVID19 has killed more of us than died in the Vietnam war’s 11 years. Some have stated this is a “great success story.”

Healthcare providers may not see this as such a great success, as COVID is crushing healthcare financials.

Research suggests almost 13 million workers have lost their health insurance due to the repercussions of COVID19. Multiplying that by 2 approximates the total number of employees plus dependents that lost coverage – 26 million.

Many will seek Medicaid coverage, but eligibility varies widely (and wildly) by state. People who don’t have coverage and contract the disease and need facility care should have their bills covered by the Feds – either at Medicare rates or via Medicaid.  Either way, reimbursement is likely half or less what their private insurer would have paid.

Anthem just informed us they expect the percentage of people covered by governmental healthcare plans to increase. The $100 billion+ health insurer saw its financial results for Q1 improve; my guess is the drop in elective procedures was a big factor.

All of this to say that COVID appears to be accelerating a trend towards a public option for health benefits – or perhaps a much bigger role for governmental programs in health insurance.

Hospital financials are getting hammered as elective procedures are way down, and many folks with all kinds of ailments are staying away for fear of coronavirus exposure. (chart from Kaufman Hall)

With receivables drying up to dust, facilities are going to redouble their efforts to collect every nickel they can from everyone they can.

Workers’ comp payers – you are hereby warned.

Willis Towers Watson has been publishing their perspectives on all things COVID19, from the impact on the LGBTQ community to a helpful discussion of paying premiums when cash is tight.

An early piece focused on employers’ considerations re workers’ comp liability for COVID19 claims. One item in particular stuck out – large employers with excess coverage should read their current communicable disease coverage details very carefully.  Friend and colleague Karen Caterino was kind enough to paraphrase for me:

For large employers purchasing excess, a multi-claimant disease incident carries the possibility of creating catastrophic financial loss.  If the transmission of a covered communicable disease is a series of incidents versus a single accident, the difference in retained loss could be significant.  A majority of work comp deductible agreements include a provision stating that the deductible applies per employee for occupational disease.  Some insurers are likely to suggest the statute requires they follow the assumption that occupational disease, by its very nature, is a series of occurrences for multiple claimant losses.

This is especially important for supermarket chains, who by now should know that paid sick leave may be the most effective risk management tool to prevent employee and patron exposure. There are many stories like this one detailing how quick, thoughtful action kept food coming while drastically reducing employee exposure.

NCCI has a helpful compendium of states‘ COVID19-related legislative and regulatory initiatives along with COVID19 FAQs.

And yes, surgical masks are quite effective at reducing viral transmission; thanks to Glenn Pransky MD for tipping me off to this research.

Finally, this is a terrific summary of what we know and don’t about how COVID19 affects the human body. It’s long, very well-written, and perfect for a lunch-time read. Spoiler alert – a lot of treatment these days is based not on extensive research but on what docs think works based on prior experience and communication with other clinicians.

From the physician author:

In the absence of data from randomized, prospective trials, we search for answers on colleagues’ Twitter accounts, in interviews with Chinese or Italian physicians, and in our patients’ charts.

What does this mean for you?

Wear a mask, and physically isolate, because we can’t take much more of this “success.”


Feb
19

Single Payer’s impact on jobs

Reality is, switching to a government-run and administered healthcare system would crush the economy – because millions would lose their jobs.

There are 22 million jobs in the US healthcare and related industries (that includes mine, one of our daughters, and her husband – they are nurses – our other daughter is in the tech business and one of her clients is a large health system; our son is also in tech and his company services medical practices.)

The private health insurance industry alone employs north of a million people. (data on this is spotty; UnitedHealthcare has 300,000, Cigna, Molina, Centene, Aetna and Anthem combined have over 180,000; there are dozens of other healthplans, PBMs, TPAs, and ancillary service providers.

On the provider side, there are over 700,000 management jobs (average salary is $86,000) and several million administrative jobs.

Many large hospitals and healthcare systems need several hundred workers just to handle billing and collections; these jobs would go away under a single payer system.

Let’s add all the college and grad school institutions that employ tens of thousands to educate people on healthcare administration, and the support infrastructure – IT companies, paper form printers, App developers, pundits and commentators, real estate occupied by insurers…you get the idea. The health care industry is at least a fifth of our economy.

If we switched to a true single payer system, millions of administrative, support, and related jobs would disappear. Remember what happened to manufacturing in the rust belt? That happened over 50 years; this would affect a much bigger share of the economy over a much shorter time.

The result would be an economic collapse that would surpass the Great Depression and devastate the economy.

Lest you think this is hyperbole, Taiwan employs a grand total of 300 people to administer a single payer healthcare system for a population of 24 million.

Using Taiwan as a basis, we’d only need 4,125 people to administer a universal single payer system.

All of the people administering Taiwan’s health system work in this one building.

What does this mean for you?

Believing government administered Single Payer can happen anytime soon requires magical thinking.


Feb
18

Single Payer is…what?

(We are reprising several posts about Single Payer; Bernie Sanders’ current status as the sorta-front-runner in the Dem race has folks wondering what this is all about) You’re going to hear a lot about Single Payer over the next few months – mostly from people who a) have an opinion about it BUT b) don’t even know what “Single Payer” is.
Before you get sucked into that discussion/argument, here’s a primer. “Single Payer” – by definition – is government-financed and government-managed health insurance. Beyond that, pretty much every country with Single Payer is unique, each with its own nuances. For example,
  • most don’t have government-employed healthcare providers; in many single payer systems, physicians, therapists, hospitals and other providers are private.
    • The UK is an exception; providers are (mostly) employed by the government
  • many are not government-operated; in many systems private insurers contract with the government to handle administration of health insurance – similar to our Medicare
    • Again the UK is an exception
Typically:
  • the government sets pricing/reimbursement policy and actual prices – similar to our Medicare
  • funding comes from some combination of employee, employer, and other taxes; in some countries, insureds pay some form of premiums – similar to our Medicare
  • it covers everyone
  • there is little to no paperwork for patients/consumers; all that is handled by the administrative agency
  • there are minimal or no deductibles, copays, or co-insurance requirements
  • people can buy into supplemental insurance through private insurers
What does this mean for you? You are now more knowledgeable than most everyone else about Single Payer.

Feb
13

Single Payer – what’s the real scoop?

(this is an update of a post from last year; given all the attention, it’s timely) It’s the worst kind of government over-reach.

It’s an easy solution to a huge problem that will cost nothing.

And everything in between. Between now and Election Day you are going to hear a lot about Medicare for All and Single Payer, and most of it will be utter nonsense.

Proponents of Single Payer/Medicare for All say it will reduce overall costs and ensure everyone in America has great healthcare; At the other end of the spectrum, it’s fiercest opponents say it will bankrupt the country while giving bureaucrats control over your family’s healthcare.

Reality is, since there is no actual agreed-upon “Medicare for All” or Single Payer legislation, each of us sees what we want to see – MFA as the Holy Grail or a Total Disaster.

Let’s take a step back and think about how voters are affected by the core problem – or rather problems, with healthcare and health insurance.

The focus on voters is critical here – most are covered by employer-based health insurance, and most of the rest are covered by Medicare. For the non-elderly:

  • Health insurance is stupid expensive.
  • For many of us, deductibles are so high “insurance” just protects you from catastrophic injuries or illnesses.
  • Insurance companies control the doctors and hospitals you can use and the care you get.
  • The paperwork is mindboggling, confusing, and adds billions in unnecessary cost.

For workers, healthcare “costs” are a combination of insurance premiums and cost-sharing payments – mostly deductibles and copayments. (While about 75% of premiums are paid by employers, economists argue that most of those premium dollars would be paid in cash wages if health insurance wasn’t provided.)

Today family health insurance premiums are more than $20,000 a year.

Over the last two decades, healthcare costs have eaten up wage increases – one of the main reasons families aren’t getting ahead.

For those who actually have to use their health insurance, it’s worse. Deductibles are so high that many families can’t afford them.

 

Add this all up, and you understand why healthcare was the top issue for most voters in the mid-terms.

Voters like simple answers to complex questions – and for many, some form of Single Payer sounds great.

The takeaway – voters want healthcare solved and they don’t care much about the details.


Feb
11

What about your pre-existing conditions?

Let’s get real folks.

“Virtually every American has someone with an existing health condition in their family at any given time” 

Dan Mendelson, CEO, Avalere

The Texas lawsuit filed by Republican Attorneys General and supported by the Trump Administration would end the ACA, aka Obamacare.

In so doing, it would end protections for those with pre-existing conditions.

Make no mistake, if Trump et al win the suit and you have to change health insurance plans, you are at real risk of losing coverage  – or having to pay so much you can’t afford it.

Despite President Trump’s assertions, there is No Republican plan to assure those with hypertension, diabetes, a history of heart disease, cancer, anxiety disorder, or any other health condition will be able to afford health insurance.

Not sure if you have a pre-ex?  Here’s a list.

What does this mean for you?

For some, this election is a matter of life and death.