Monday Morning Musings

A new week; a clean slate; starting over.  All good things.  Let's see about the news:

If the Supreme Court strikes down the individual mandate, what will states do?   Some states -- the states that are already working on Exchanges and implementing other aspects of health reform -- may well enact their own individual mandates.  Surely, insurers will be pressing this issue if they are still required to cover people with pre-existing conditions since adding young, healthy people to the pool is necessary to spread the cost of insuring those with pre-existing conditions. 

I'm really upset about this one.  Nonprofit hospitals are paid by the federal government to provide charity care to the poor.  However, the hospitals are getting increasingly aggressive.  Here's one example of a woman who probably was eligible for charity care, but instead, the hospital sent her claim to collections, threatened to garnish her wages, and threatened to sue her over $1800.  These hospitals don't pay taxes because they are supposed to be operating for the public good.  The hospital says they try to determine whether the patient is eligible for charity care, but blames the patient for not providing all the necessary information or otherwise not following the rules.  At the very least, hospitals who do this should lose their tax exempt status.

Years ago, we learned that the company that was responsible for reporting "usual and customary" rates to insurers for calculating out of network reimbursement was owned by UnitedHealth Group -- a clear conflict of interest that was stopped by a settlement agreement with the NY Attorney General.  Now, as insurers continue to diversify, we have to look for these conflicts carefully.   For example, EHR is supposed to help hospitals and other providers fight with insurers to make sure they pay sufficiently and timely.  But EHR was purchased by UnitedHealth Group.  As diversification flourishes, we have to be careful to look for these sorts of problems.

Service dogs are helping soldiers returning from Iraq with PTSD.  We've been learning a lot about service dogs lately; we have a client who's autistic who uses a service dog to keep him calm and focused.  The article linked here is about service dogs who help Iraq veterans who use service dogs to keep them calm when triggers arise that previously would have freaked them out.  These are not your usual dogs; they are highly trained and serve a very specific purpose, depending on the patient's needs.  The more I learn about the use of service dogs, the more respect I have for them and for those who train them. 

Type 2 diabetes is increasing in America's children, associated with obesity and much harder to treat than in adults.  This type of diabetes is new in children -- rarely seen before 1990.  Although it's still rare, it's growing.  And although adults with type 2 diabetes usually get by with oral medications, kids end up needing injections of insulin.  And they're looking at a lifetime of disease.  We need to figure out why this is happening and stop it before it happens.  All of the pediatric patients studied were obese.  So take your kids outside to play.  Don't reward them with high-calorie snacks.  Make food about fuel rather than pleasure.  I know these things only because my parents did everything wrong when it came to my weight.  Be smarter.

Connecticut Children's Medical Center and Athem Blue Cross Blue Shield of CT cannot come to agreement on reimbursement rates.  So children enrolled in Anthem cannot get their insurance to cover their CCMC doctors.  This is disastrous for these kids.  If you are in this situation, contact the Office of the Health care Advocate at 866-466-4446.  They're keeping track of the problems, although none of us are sure what can be done.  I hope the parties can reach a compromise.  It's about the kids; don't forget that. 

Have a great day -- or try to.  Jennifer

This Pisses Me Off

The House passed a bill that would pay for reducing student loan interest by cutting preventive health care.  Speaker Boehner calls the Prevention and Public Health Fund a "slush fund."  These are funds for cancer screening, child immunization, smoking cessation and nutrition.  In particular, the cancer screening funds are primarily for women -- breast and cervical cancer.  When did our health and the health of our children become "slush" that is expendable?  If the GOP wants to convince us that the "war on women" is a figment of the liberal media, perhaps they should stop targeting programs for women and children.  Are you not outraged?  You should be.  Jennifer

Finally Friday Edition

I do so love Fridays.  But today is bittersweet.  Our Administrative Assistant, Echo Kendall, is leaving us today.  She's about to give birth to a baby boy, and will be able to spend her time with him after he's born, not working, at least for the time being.  Although we are thrilled with her replacement, Jillian Szymanski, it's always sad when someone who's been a part of this organization for a good long time leaves, even if for the best of reasons.  But we are going to have a fun day today -- a little send-off with all of our love and best wishes.  Life moves on, but love remains.  I've known Echo since she was an infant; to have been able to spend her pregnancy with her has been a great gift that means so much to me.  I can't wait to meet her son!  Echo, we love you and will miss you -- and you'd better come visit once in awhile!

Okay -- wipe away the tears now -- here are a few of today's health highlights:

Remember medical loss ratios?  That's the percentage of premium dollars that go to paying for health care.  Under health reform, insurers must spend 80 or 85 percent of premium dollars on health care.  If they don't make that target, they have to pay rebates to their insureds.  Well guess what?  Insurers are expected to refund about $1.3 billion that will be coming this summer.  Still against health reform?  Still think it does nothing to control premium prices?  I bet you'll like that check when it shows up in your mailbox!

According to a new General Accountability Office report, as many as 112 million Americans have pre-existing conditions.  So if health reform falls, those people will be locked into their current insurance -- or if they lose that, they will not be able to get insurance at all.  Still against health reform?

After yesterday's story about debt collectors planted in emergency rooms trying to get money from people before they even receive care, Congressman Pete Stark has asked the Centers for Medicare and Medicaid Services (CMS) to investigate. Clearly, someone needs to look into this.  I'm glad to see it being taken seriously. 

As you know, Dr. Pauline Chen's pieces are among my favorites.  Today, she asks: Does medicine encourage gay doctors?  It appears, from her anecdotes, that the answer is no -- there's blatant discrimination against gay doctors, according to her experience.  While this information is anecdotal only, it's a poignant and sad reality.  We are grateful to Dr. Chen for talking about this issue.

Health care is changing to emphasize quality of life.  Give patients real life goals like being able to work or go to dinner with friends instead of focusing only on blood sugar levels or other scientific measures that are harder for patients to connect with.  This helps patients be able to measure their progress in between doctor appointments, and engages them in a more active role, managing their own care.  This is so totally right.

And that's what grabbed me today in my perusal of the papers.  Have a great day and a great week-end!  Jennifer

Thursday's Thoughts

I hadn't planned on spending next week interviewing candidates for our staff attorney position, but if chronic illness teaches us anything, it's that life is not predictable.  Our only choice is to roll with the punches.  So I'm rolling.

I find this to be interesting.  There's supposedly a lot of opposition to health reform, but two conservative Dems in Pennsylvania lost their party's primaries to two liberals, and the story is that it's largely due to the fact that the incumbents voted against health reform.  Early on in the polling about health reform, the questions were specific enough so that we know that a lot of people who were opposed did not think the law went far enough in the absence of single payer or a public option.  I wonder if that's still the case, so the polling against the law is not all from health reform opponents.  I'm not sure how else to explain these primary results -- and it makes sense to me, since it's quite clear that the law, in fact, does not go as far as it really should if we were trying to control costs as well as achieve near universal coverage.  The best way to keep costs down would have been to have a public option against which the commercial plans would have had to compete.  A lot of people on the left are still upset about that loss.  So is some of the opposition to health reform coming from the left?  Maybe so.

Here's another installment from the young woman undergoing a bone marrow transplant.  She's had the transplant, but she's in isolation to prevent infection because her immune system is essentially non-existent due to the chemo that preceded the transplant.  She's waiting for her brother's healthy cells to engraft in her bone marrow.  She's lost her hair and can't eat.  And she's a hero.  Everybody who fights that hard to live is a hero.  I can tell you for sure that I wouldn't do it.  After my last bout with life-threatening illness, I have never bounced back completely.  What I went through was grueling and life-altering.  I will never be the same.  And I will never do it again.  Everybody who chooses this kind of fight is more courageous than I will ever be.  I am in awe. 

The House Appropriations Committee has gone ahead and passed spending targets that change the deal they made last August.  Remember the fight over raising the debt ceiling?  Congress agreed that a super-committee would try to agree on $1.5 trillion in cuts, and if they couldn't, there were automatic triggers that would take effect in 2013.  Well, since the super-committee failed, the triggers are looming and the House GOP is unhappy with the deal they made.  So they want to change it -- and that's bound to lead to a very partisan battle this summer, with the threat of a government shut-down in October, right before the election.  Who will the voters blame for that, I wonder?  Ugh -- what a mess!

Meanwhile, the health reform law is being dragged into the fight over student loans.  Congress is debating a measure that would stop interest rates from increasing.  Speaker Boehner says he'd pay for that with health reform funding -- what he calls a "slush fund."  Yeah, because providing subsidies to help middle-income families afford health insurance is definitely a slush fund kind of expenditure.  I just don't get it.  What would the GOP do to fix the status quo in health care, with unaffordable premiums, the rise in high-deductible plans, and the number of people who can't get care due to cost?  Until they answer that question, they should not have a right to criticize the plan that's already in place.

Ever wonder how much doctors earn?  Well, here are some figures.  I suspect this is only income from their practice of medicine, without the extras for research, public speaking, and so on.  But I have to say it's less than I thought.  Interesting. 

The Connecticut House of Representatives has passed a bill legalizing medical marijuana.  I'm not sure what this is worth, though, in light of the continued federal crack-downs on medical marijuana use.  Too bad, though, that the feds are taking this position.  I'm entirely convinced that marijuana is an under-utilized weapon in the arsenal to treat chronic pain, nausea, and other symptoms.  And I don't understand the basis for prohibiting it.  But in great local news, the House also passed a bill that would add consumers to the Board of the Connecticut Health Insurance Exchange and make our Healthcare Advocate, Vicki Veltri, a voting member.  About time.  Now, the Senate needs to pass it -- soon. 

That's it for today.  Have a great one.  Jennifer

Wednesday Already?

So this really blows me away.  A Minnesota debt collector has placed employees in emergency rooms and demanding payment before the patient even receives treatment.  The New York Times suggests that this may be happening all over the country.  And it is an outrage.  The debt collectors had access to medical information, violating privacy rules.  They dress so that they are indistinguishable from hospital employees.  They may not have identified themselves as debt collectors, as required under the Fair Debt Collection Practices Act.  Maybe I'm just missing something, but since the federal government pays nonprofit hospitals millions of dollars to compensate them for uncompensated care, I'm not sure why the hospitals feel so squeezed.  But I do know that they have no place in treatment areas of hospitals -- period.

And here's an opinion piece that makes me really mad.  The article says that Social Security disability is a bad thing, that it's too easy to get benefits, that it takes people out of the job market prematurely and slows economic growth.  You know, I talk to a lot of people on disability -- and a lot of people who are trying to get disability.  It's certainly not easy to get -- that much is for sure.  The article also says we can fix this by making employers buy private disability insurance so that they feel the pain every time they drive an employee to disability.  Bosses would then provide rehab and improve working conditions.  Really?  I do agree that we need to find more ways for disabled people to work.  So many people could earn a living if they could work from home.  But in my experience, the companies who offer private disability insurance are no less likely to push people to disability.  The problem is far more complex than this -- for example, if we had better, more affordable health care, people wouldn't get so sick that they end up on disability.  How about stopping the trend to high deductible health insurance so people would get the care they need to stay healthy and employed?  Yes, there are answers, but the answer isn't making disability harder to get than it already is.

A new study shows that painkiller abusers start at home, getting drugs from family or friends.  Kids find drugs in medicine closets and experiment.  Okay, then.  It seems that this should be an easy enough fix.  Parents, lock your drugs up where they can't be found by your kids.  If you're on pain meds, don't share them.  But what I worry about most of all when I read articles like this is that the crack down on pain meds is hurting people with legitimate chronic pain who are finding it increasingly difficult to get the meds they need.  So the people who have pain meds legitimately have to take responsibility for their use if you want pain meds to be available when you need them.

Join Costco and buy Aetna health insurance?  Sort of interesting.  I think insurers are trying to use agents and brokers less because commissions go on the administrative side of the medical loss ratio formula (percentage of premium dollars spent on health care).  Avoiding paying commissions is one way to make more room for other administrative costs -- like salaries and bonuses.  Expect to see more retail selling of health insurance, I predict.

And those are the stories that interested me today.  What do you think?  Jennifer

Staff Attorney Needed

Advocacy for Patients with Chronic Illness, located in Farmington, Connecticut, is looking for a staff attorney.  Primary responsibility is to prepare very complex insurance appeals, as well as to represent clients in employment and school matters, help locate resources for people in need, and supervise student interns.  We are willing to train, but Bar membership is required.  The salary is $45,000, non-negotiable.  Must be in Connecticut; the job cannot be done long-distance. 

The work is great.  Every once in awhile, we save a life.  And it's great training for a young lawyer.  If you're interested, please email your resume to patient_advocate@sbcglobal.net.  Jennifer

Tuesday Tidbits

I have to start with the article on the front page of the New York Times about out of network benefits.  I'd be profiling this one even if I were not in it.  This is a very important issue for consumers.  If you have insurance that allows you to go out of network, your policy says it will cover 70 or 80 percent of the "allowed amount."  You may think that means they'll pay 80% of what your doctor legitimately charges, but you would be dead wrong.  It's 80 percent of what the insurance company thinks your doctor should have charged, not what they actually charge. 

It used to be that insurers paid 80 percent of "usual and customary" charges.  Back in 2009, the NY Attorney General reached a settlement with insurers that would stop them from using cost data they got from a company called Ingenix, which was a United Health Group subsidiary -- clearly not unbiased -- to determine what was "usual and customary."  Under the settlement, insurers no longer could use Ingenix data.  However, a nonprofit organization -- FAIR Health -- was formed to receive and update that data and make it available to payers, providers, and consumers.

The insurance industry, though, saw an opening.  Many of them have switched now, from usual and customary to "allowable amount," defined as pretty much whatever they say it is.  In my case, Anthem Blue Cross Blue Shield of Connecticut pays whatever the Blue Cross in the provider's state pays.  In this case, Empire Blue Cross uses 250 percent of Medicare -- and when you have an upper endoscopy on the same day as a colonoscopy, they only pay half of the allowable amount for the upper endoscopy, or $220 out of an $1800 bill.  You know what happens -- people stop having scopes as often as they should because they can't afford it.  So they wait.  Until they are sick and don't have a choice.  And by then, they need a lot more than just scopes.  It's a racket for the insurers -- and consumers need to know about it.  Which is why I gave the New York Times all of my explanations of benefits and let them run with it.  Hopefully, it will illustrate the point for many consumers who need to know how their insurance works before they go for care, not after. 

And here's a related piece on hospital pricing, which also is all over the map.  The cost of a simple appendectomy is all over the place -- and about one-third of the price differential cannot be accounted for based on any differences in the procedure itself. 

The second story of the day is the economic outlook of Social Security and Medicare.  The Social Security trust fund will run out of money in 2033, and Medicare in 2024.  But the Social Security disability account will go broke in 2016 -- not so long from now.  Some how, we are going to have to reform these systems without changing their essential character.  That may mean a higher retirement age, to start with.  The Social Security disability system is so broken, though, that it needs a much bigger fix.  They have to find a better way to make disability determinations.  There are too many appeals -- but that's because too many righteous claims are being denied, so there are too many appeals, and the whole system is bogged down.  I wonder how much of their budget they spend on administration.  I bet they could do it a lot cheaper if they did it right.

What if the Supreme Court strikes down only part of the health reform law?  What then happens to the rest of it?  Will the Supreme Court wade through all 2700 pages and figure out what parts survive and which don't?  Or will they send it back to a lower court -- or leave it to Congress to fix it?  No matter what, if the  Court does anything other than uphold the law, there will be chaos.

And here's a piece on travel insurance.  But read the fine print.  It always excludes pre-existing conditions.

Finally, apparently the days of debtors' prisons has returned. Here's a hair-raising story about a breast cancer survivor who was jailed for a $280 medical bill that she didn't even actually owe.  Such an outrage.  Illinois -- where this woman lives -- is considering legislation to outlaw debtors' prisons.  Should have been done long ago. 

And that's it for today.  Have a great day!  Jennifer