Sec.113 INSURANCE RATING RULES
a) allows for limited variations in rates QHBPs charge enrollees
b)1) requires a study of large groups, self-insured employers vs. those with a bought plan, including solvency issues for the self-insured.
b)2) requires a report on this study to with recommendations to make sure that there are no incentives for smaller employers to self-insure, or which will "create adverse selection in risk polls of large group insureres of self insured employers". Is this adverse selection adverse to the insurers or the insured?
Sec. 114 Nondiscrimination in benefits.
a) To understand this properly you have to look us sec 702 ERISA 1974, Sec 2702 Public Health Services Act, and Sec 9802 of the Internal Revenue Code of 1986. Which I haven't got to yet.
b) requires parity in mental health and substance abuse benefits, making the provisions of Sec 2705 of the PHSA applicable to all plans, both individual and group, as long as they are not superceded by or inconsistent with Subtitle C.
Sec. 115 ENSURING ADEQUACY OF PRIVIDER NETWORKS.
a) QHBPS areto have enough profiders in their networks that their enrollees can actually get the covered services. What happens if no QHBPs in a geographic area can get enough folks to accept their plans?
Transparency in the cost-share differential between in network and out-of-network is required. Every plan I've ever had had this in the enrollment book and printed on the insurance cards.
Sec. 116 ENSURING VALUE AND LOW PREMIUMS
a) seems to basically mean that if a QHBP takesi n more than a pre-set % of what it pays out it must rebate the excess to enrolees. The term medical loss ratio is used, which seems to mean the portion of premiums taken in that is used to cover enrollees claims.
b) the Commissioner is to use HHS methodology to set the MLR. It must be high enough to get insurers to participate. Though if the MLR is what they pay out, it would seem that they mean setting the percentage of premiums NOT spent on enrollee claims high enough.
Friday, July 31, 2009
"Fixing" health care
I was thinking about this topic this morning (surprise) and wondered: in all this rush to "fix" health care in the US, have any of those folks in Washington DC who are writing the bills actually studied the problem to find out not only what things aren't working for folks (costs are high, and not everyone has insurance which will cover all the unexpected stuff), but also what works?
We're told that 85% of Americans are pretty happy with how things are now. Have any policy makers actually talked to them to find out what they're happy with?
It's as if my current employer suddenly started getting surveys back saying 15% of our patients were unhappy, so the solution is obviously to raze the whole building to the ground, fire everyone, and start from scratch, with no real data as to what made the other 85% satisfied.
We're told that 85% of Americans are pretty happy with how things are now. Have any policy makers actually talked to them to find out what they're happy with?
It's as if my current employer suddenly started getting surveys back saying 15% of our patients were unhappy, so the solution is obviously to raze the whole building to the ground, fire everyone, and start from scratch, with no real data as to what made the other 85% satisfied.
Monday, July 27, 2009
John Conyers is an ass.
John Conyers actually has the nerve to say there is no reason for our legislators to read the bills put before them. Since the health care bill would take two days and two lawyers to understand, they shouldn't bother.
Patronizing is one of the nicer terms I can think of. I mean, us poor stupid voters, how can we think that our representatives ought to know what they're doing when they vote on something?
Here is the news item, with a video clip :http://www.cnsnews.com/public/content/article.aspx?RsrcID=51610&print=on
Edited on Friday, July 31st to add:
I've been told that what he was saying was that there was no point in reading the current version of the bill because it was that long and complex and was going to be changed in committee anyway.
However.... it will probably be easier to understand the changes if one understands what was there to be changed, and if they had come up with a bill out of committee on Wednesday, I'd be willing to bet that they'd still expect the House to vote on it by today, even if the members hadn't had the two days and two lawyers to help them out.
Patronizing is one of the nicer terms I can think of. I mean, us poor stupid voters, how can we think that our representatives ought to know what they're doing when they vote on something?
Here is the news item, with a video clip :http://www.cnsnews.com/public/content/article.aspx?RsrcID=51610&print=on
Edited on Friday, July 31st to add:
I've been told that what he was saying was that there was no point in reading the current version of the bill because it was that long and complex and was going to be changed in committee anyway.
However.... it will probably be easier to understand the changes if one understands what was there to be changed, and if they had come up with a bill out of committee on Wednesday, I'd be willing to bet that they'd still expect the House to vote on it by today, even if the members hadn't had the two days and two lawyers to help them out.
HR 3200, Sec. 100, 101, 102, 111, 112.
OK, I started reading this thing and taking notes on it yesterday.
Text in red is directly from the GPO pdf of the bill.
Dr. Who is much more interesting.
DIVISION A - AFFORDABLE HEALTH CARE CHOICES
Sec. 100 PURPOSE; TALBLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS
a)1) The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending.
Will the bill ever address how you can increase the number of people utilizing our health care system without increasing the amount you need to spend?
a)2) actually uses the word "broken" to describe aspects of the health care system.
a)3) discusses how the bill will reform health insurance.
a)4) Entitled HEALTH DELIVERY REFORM
First the snarky question - how do you deliver health? Second - similar question to a1, how do you increase quality of health care to more people while spending less per person?
b) the table of contents
c) general definitions used throughout the bill, with many references to ERISA 1974
c)25) Y1 ... and similar subsequently numbered terms, mean 2013 and subsequent years, respectively.
Do most folks who are pushing for this realize that it won't help anyone for at least 4 years?
Now we get to the actual TITLE I of the bill - PROTECTIONS AND STANDARDS FOR QUALIRIED HEALTH BENEFITS PLANS.
Subtitle A - General Standards
Sec. 101 REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE
That is an exact quote from the GPO copy of the bill. Does anyone out there know what it means? Otherwise the section is actually comprehensible, at least to someone with a postgraduate level of education.
Sec. 102 PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE
a) defines grandfathered coverage. If I'm reading this right, only individual plans (not group, or employer plans) can be grandfathered. However, per b)1) there is a 5 year transition period for group plans.
a)1) beginning with day 1 of Y1, no new enrollees in existing plans, except for adding dependents.
a)2) NOTHING about a plan can change except for the premiums or other changes required by law.
a)3) defines the premium increase rules.
b)1) by the beginning of Y6, all employment based plans must meet requirements of Sec 101 for QHBPs, i.e., unless your plan already met the requirements on Day 1, Y1, YOU CAN NO LONGER KEEP YOUR
PLAN
b)2) beginning with Day1, Y1, the only individual plans for new enrollees must be QHBPs and must be Exchange participating.
Subtitle B - Standards Guaranteeing Access to Affordable Coverage
Sec. 111 PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS
A short section, only one paragraph, which prohibits QHBPs from imposing pre-existing condition exclusions or limits.
Sec. 112 GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS
This is a little unclear on initial reading, partly because it references sections 2711 and 2712 of the Public Health Service Act, but it sounds like once someone is in a plan, as long as they pay their premiums they can never be dropped, for any reason. As a reasonable person, I would read this section to say that a) an insured can never be dropped unless they fail to pay their premiums, and b) as long as a single insured wishes to keep their plan, the insurer MUST keep insuring them.
Does this mean that once a plan is offered the insurance company can never stop offering it? i.e., if BigInsCo decides they no longer want to offer group plans, they must continue for as long as a single
client wishes to use that plan?
Text in red is directly from the GPO pdf of the bill.
Dr. Who is much more interesting.
DIVISION A - AFFORDABLE HEALTH CARE CHOICES
Sec. 100 PURPOSE; TALBLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS
a)1) The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending.
Will the bill ever address how you can increase the number of people utilizing our health care system without increasing the amount you need to spend?
a)2) actually uses the word "broken" to describe aspects of the health care system.
a)3) discusses how the bill will reform health insurance.
a)4) Entitled HEALTH DELIVERY REFORM
First the snarky question - how do you deliver health? Second - similar question to a1, how do you increase quality of health care to more people while spending less per person?
b) the table of contents
c) general definitions used throughout the bill, with many references to ERISA 1974
c)25) Y1 ... and similar subsequently numbered terms, mean 2013 and subsequent years, respectively.
Do most folks who are pushing for this realize that it won't help anyone for at least 4 years?
Now we get to the actual TITLE I of the bill - PROTECTIONS AND STANDARDS FOR QUALIRIED HEALTH BENEFITS PLANS.
Subtitle A - General Standards
Sec. 101 REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE
That is an exact quote from the GPO copy of the bill. Does anyone out there know what it means? Otherwise the section is actually comprehensible, at least to someone with a postgraduate level of education.
Sec. 102 PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE
a) defines grandfathered coverage. If I'm reading this right, only individual plans (not group, or employer plans) can be grandfathered. However, per b)1) there is a 5 year transition period for group plans.
a)1) beginning with day 1 of Y1, no new enrollees in existing plans, except for adding dependents.
a)2) NOTHING about a plan can change except for the premiums or other changes required by law.
a)3) defines the premium increase rules.
b)1) by the beginning of Y6, all employment based plans must meet requirements of Sec 101 for QHBPs, i.e., unless your plan already met the requirements on Day 1, Y1, YOU CAN NO LONGER KEEP YOUR
PLAN
b)2) beginning with Day1, Y1, the only individual plans for new enrollees must be QHBPs and must be Exchange participating.
Subtitle B - Standards Guaranteeing Access to Affordable Coverage
Sec. 111 PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS
A short section, only one paragraph, which prohibits QHBPs from imposing pre-existing condition exclusions or limits.
Sec. 112 GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS
This is a little unclear on initial reading, partly because it references sections 2711 and 2712 of the Public Health Service Act, but it sounds like once someone is in a plan, as long as they pay their premiums they can never be dropped, for any reason. As a reasonable person, I would read this section to say that a) an insured can never be dropped unless they fail to pay their premiums, and b) as long as a single insured wishes to keep their plan, the insurer MUST keep insuring them.
Does this mean that once a plan is offered the insurance company can never stop offering it? i.e., if BigInsCo decides they no longer want to offer group plans, they must continue for as long as a single
client wishes to use that plan?
Why I don't favor a rush to "fix" health care
I spent several years on Tricare (it's still my secondary), and rather longer before that in Ireland in their NHS system. Which is why I worked hard to get a good job so I would have something NOT run by a gov't. The Navy tried quite hard to kill my eldest child, and I still have occasional problems stemming from the post-appendectomy abscess in Galway ("Oh, but 10% to 20% of all appendectomies get post-op abscesses!")
At least HR 3200 is currently not quite as bad as HR 676 - Medicare for all! No co-pays, ever! No for-profits of any kind anywhere in the health care system (we'll buy them out forcibly)! The gov't will decide in advance how much they will allow a geographical region to spend on care for the year! (Ask the UK how that's doing - no money for cleaning and other basic supplies.) A rather Orwellian/Soviet-sounding "National Board of Universal Quality and Access"! What could go wrong?
Yes, the current system needs some fixing. But handing it over to gov't bean counters to decide whether the only treatment that will cure me is "cost-effective" or if I’m far enough up the queue is not something I ever want to deal with again.
One place to start reform is letting the uninsured pay the same as is accepted from insurance. I've been charged $70 for an inhaler when Tricare's computers were down and there was no proof that I was still insured. Two days later when they were back up, the pharmacy accepted a total of $40 between insurance and co-pay for the same med. But federal law requires that they charge the uninsured full freight, even though they must accept the lower amount from the feds. Why should a lack of insurance mean you have to pay 50-100% more for all your medical care? I'd like to see a provider being allowed to recieve the same amount for the same service, no matter who pays. The feds are responsible for that, so they could fix it pretty fast, if they were willing to. However, if they did, they'd have to up what they pay, since providers tend to lose money on the federal patients, and have to make it up on privately insured, and uninsured.
We could also buy basic private insurance for all the legally-here uninsured for far less over the next 10 years than the projected costs of HR 3200.
I just worry that if we get system which divorces end users even more from the costs, inspite of gov't rhetoric, the only way to contain costs will be rationing, and then we'll end up with folks dying of curable diseases, simply because it costs too much to do detection testing, such as pap smears on women under 25, because we know that they never get cervical cancer, or because at 80 how much use will you really get out of that pace-maker?
The problems with our current delivery of quality health care and - perhaps even more so - sick care are complex, and to ram through a fix on a rapid time frame, designed by who-knows-who, and voted on by legislators who don't even read, much less understand, what they vote on, just so we can say we "fixed health care!" will create even more problems.
Utah has what looks to be a distinct possibility in improving access to health care, MA's system is going (gone?) broke, Hawai'i tried something for kids which they had to stop within 7 months, because they didn't account for human nature and it cost way more than expected. Let's see how all these experiments work before we rush into fixing a damaged, but still functional-for-the-majority system.
At least HR 3200 is currently not quite as bad as HR 676 - Medicare for all! No co-pays, ever! No for-profits of any kind anywhere in the health care system (we'll buy them out forcibly)! The gov't will decide in advance how much they will allow a geographical region to spend on care for the year! (Ask the UK how that's doing - no money for cleaning and other basic supplies.) A rather Orwellian/Soviet-sounding "National Board of Universal Quality and Access"! What could go wrong?
Yes, the current system needs some fixing. But handing it over to gov't bean counters to decide whether the only treatment that will cure me is "cost-effective" or if I’m far enough up the queue is not something I ever want to deal with again.
One place to start reform is letting the uninsured pay the same as is accepted from insurance. I've been charged $70 for an inhaler when Tricare's computers were down and there was no proof that I was still insured. Two days later when they were back up, the pharmacy accepted a total of $40 between insurance and co-pay for the same med. But federal law requires that they charge the uninsured full freight, even though they must accept the lower amount from the feds. Why should a lack of insurance mean you have to pay 50-100% more for all your medical care? I'd like to see a provider being allowed to recieve the same amount for the same service, no matter who pays. The feds are responsible for that, so they could fix it pretty fast, if they were willing to. However, if they did, they'd have to up what they pay, since providers tend to lose money on the federal patients, and have to make it up on privately insured, and uninsured.
We could also buy basic private insurance for all the legally-here uninsured for far less over the next 10 years than the projected costs of HR 3200.
I just worry that if we get system which divorces end users even more from the costs, inspite of gov't rhetoric, the only way to contain costs will be rationing, and then we'll end up with folks dying of curable diseases, simply because it costs too much to do detection testing, such as pap smears on women under 25, because we know that they never get cervical cancer, or because at 80 how much use will you really get out of that pace-maker?
The problems with our current delivery of quality health care and - perhaps even more so - sick care are complex, and to ram through a fix on a rapid time frame, designed by who-knows-who, and voted on by legislators who don't even read, much less understand, what they vote on, just so we can say we "fixed health care!" will create even more problems.
Utah has what looks to be a distinct possibility in improving access to health care, MA's system is going (gone?) broke, Hawai'i tried something for kids which they had to stop within 7 months, because they didn't account for human nature and it cost way more than expected. Let's see how all these experiments work before we rush into fixing a damaged, but still functional-for-the-majority system.
Thursday, July 23, 2009
HR 3200
So I'm starting to read this 1000+ page monstrosity. Lets see if I can make any sense of it....
Thursday, July 02, 2009
Response to a responses to post at Cranky Prof's place.
Here is the original post and comments.
Most hospitals and doctors in this country are more than happy to work with folks with no insurance. Especially the non-profit hospitals, such as the one I work at. We have foundations and other programs specifically to help people in your position. I know of no-one who has been denied lifesaving treatments solely because of lack of insurance or another way to pay. If you get your insurance through your employer, especially if it's a larger employer, the plan they offer HAS to take you, though some do deny payments on pre-existing conditions for up to 12 months. After that period, you ARE covered. And I know a lot of doctors who would rather do so-called charity work, than see medicaid or medicare patients, because at least with the charity case, their office doesn't have to spend hours trying to get the gov't to cough up the insurance payment, which is always less than the cost of the billing office's time, never mind the doctor's. And they legally DO have to bill the gov't, they can't just write it off.
I am a medical librarian, so I get to read a lot of the British medical literature - we subscribe to both Lancet and BMJ as well as some of the specialty journals. When patients have to wait over 6 months between cardiac imaging studies and the stenting those studies show is required, patients die. When studies show that of patients considered curable at the time they go on the list to recieve chemo or radiation treatment for cancer at least 10% have their disease advance to the uncurable stage before they can even begin treatment, it is obvious to most that that system is far more broken than the one in the US.
Remember, that if your insurance denies you, you have options which include legal, such as suing the bastards, changing your insurance, and if the bill is small enough, paying for it yourself. In a lot of nationalized systems, you aren't allowed to pay for procedures the gov't plan won't cover. For that matter, if the gov't plan won't cover it, the doctor probably can't even offer the procedure. If there is only one plan nationally, and it only covers certain drugs within a class, the other drugs cease to be available, as they are no longer financially viable for the manufacturer. I can't use albuterol sulfate for nebulizer treatments, since it makes me throw up for the first few doses, and then attacks my guts, which take years to recover (if ever). If the gov't plan becomes the only one, and they decide that they're only going to cover generic albuterol, and not Zopenex, I'm in deep s**t the next time I get bronchitis or pneumonia, because the xopenex will no longer be there at all, no matter how it's paid for.
I lived in Ireland for 8 years and because of my age I was on the national health system, and the waiting for anything other than my GP was months, and a lot of the stuff that had to be done at clinics was stuff my GPs here in the States have always been able to do in their offices. I've had to deal with only one drug in a given class being allowed, and that was one I had vile reactions to, so my options was to pay myself (very expensive) or do without. I was told I had a 6 to 12 month waits to have a "wart" removed at the clinic, when it wasn't even a wart, and if my GP hadn't been willing to inject a local and attack it with a scalpel, I'd have waited the 9 months or so for ineffective treatment, and then another God-knows-how-long for another appointment for them to try to figure out what it was (a dermatofibroma) and then who knows how much longer after that for an appointment to have it removed. In the US I made one appointment with a dermatologist, who looked at it (it had grown back due to not being completely excised in Ireland) and removed it that visit. And yes, my insurance covered it, but I bet it cost them a lot less than the three visits would have cost the Irish NHS.
Our system is hardly perfect, but instituting a gov't plan which due to it's subsidy by the gov't will put all the private insurers out of business it not the way to go. When patients are insulated from the actual costs of their treatments, a lot of unnecessary stuff is done (e.g. it is quite possible to diagnose appendicitis without a $2K CT scan, which also exposes the patient to LOTS of unnecessary radiation). And when there is only one plan and it's run by the gov't there will be no recourse when they tell you you're too old for a kidney transplant or a hip replacement, or not sick enough for the drugs which may not cure the problem but which will allow you to have a decent quality of life.
Most hospitals and doctors in this country are more than happy to work with folks with no insurance. Especially the non-profit hospitals, such as the one I work at. We have foundations and other programs specifically to help people in your position. I know of no-one who has been denied lifesaving treatments solely because of lack of insurance or another way to pay. If you get your insurance through your employer, especially if it's a larger employer, the plan they offer HAS to take you, though some do deny payments on pre-existing conditions for up to 12 months. After that period, you ARE covered. And I know a lot of doctors who would rather do so-called charity work, than see medicaid or medicare patients, because at least with the charity case, their office doesn't have to spend hours trying to get the gov't to cough up the insurance payment, which is always less than the cost of the billing office's time, never mind the doctor's. And they legally DO have to bill the gov't, they can't just write it off.
I am a medical librarian, so I get to read a lot of the British medical literature - we subscribe to both Lancet and BMJ as well as some of the specialty journals. When patients have to wait over 6 months between cardiac imaging studies and the stenting those studies show is required, patients die. When studies show that of patients considered curable at the time they go on the list to recieve chemo or radiation treatment for cancer at least 10% have their disease advance to the uncurable stage before they can even begin treatment, it is obvious to most that that system is far more broken than the one in the US.
Remember, that if your insurance denies you, you have options which include legal, such as suing the bastards, changing your insurance, and if the bill is small enough, paying for it yourself. In a lot of nationalized systems, you aren't allowed to pay for procedures the gov't plan won't cover. For that matter, if the gov't plan won't cover it, the doctor probably can't even offer the procedure. If there is only one plan nationally, and it only covers certain drugs within a class, the other drugs cease to be available, as they are no longer financially viable for the manufacturer. I can't use albuterol sulfate for nebulizer treatments, since it makes me throw up for the first few doses, and then attacks my guts, which take years to recover (if ever). If the gov't plan becomes the only one, and they decide that they're only going to cover generic albuterol, and not Zopenex, I'm in deep s**t the next time I get bronchitis or pneumonia, because the xopenex will no longer be there at all, no matter how it's paid for.
I lived in Ireland for 8 years and because of my age I was on the national health system, and the waiting for anything other than my GP was months, and a lot of the stuff that had to be done at clinics was stuff my GPs here in the States have always been able to do in their offices. I've had to deal with only one drug in a given class being allowed, and that was one I had vile reactions to, so my options was to pay myself (very expensive) or do without. I was told I had a 6 to 12 month waits to have a "wart" removed at the clinic, when it wasn't even a wart, and if my GP hadn't been willing to inject a local and attack it with a scalpel, I'd have waited the 9 months or so for ineffective treatment, and then another God-knows-how-long for another appointment for them to try to figure out what it was (a dermatofibroma) and then who knows how much longer after that for an appointment to have it removed. In the US I made one appointment with a dermatologist, who looked at it (it had grown back due to not being completely excised in Ireland) and removed it that visit. And yes, my insurance covered it, but I bet it cost them a lot less than the three visits would have cost the Irish NHS.
Our system is hardly perfect, but instituting a gov't plan which due to it's subsidy by the gov't will put all the private insurers out of business it not the way to go. When patients are insulated from the actual costs of their treatments, a lot of unnecessary stuff is done (e.g. it is quite possible to diagnose appendicitis without a $2K CT scan, which also exposes the patient to LOTS of unnecessary radiation). And when there is only one plan and it's run by the gov't there will be no recourse when they tell you you're too old for a kidney transplant or a hip replacement, or not sick enough for the drugs which may not cure the problem but which will allow you to have a decent quality of life.
Tuesday, February 17, 2009
Watching the DOW tank
Interesting how this bill that everyone was so desperate to get passed (do it now or we'll all DIIEEEEE!!!!!) isn't reassuring the markets. Porkulus is being signed today, and the markets are already down another 250. They are obviously feeling stimulated.
And concerning the actualy signing.... Remember how everyone got so upset about the car company executives flying to DC on their corporate jets. It was wasting fuel and bad for the environment, much better to spend hours in a "green" car? Well, it's just fine for the administration to fly one of the (D) senators back to DC from his mother's wake so they could get this thing passed. And then O flies himself and his family back to Chicago for the weekend, then back to DC yesterday, and off to Denver today. Between that and keeping the Oval Office at over 80° what's his carbon footprint? How come only us peons have to conserve?
And concerning the actualy signing.... Remember how everyone got so upset about the car company executives flying to DC on their corporate jets. It was wasting fuel and bad for the environment, much better to spend hours in a "green" car? Well, it's just fine for the administration to fly one of the (D) senators back to DC from his mother's wake so they could get this thing passed. And then O flies himself and his family back to Chicago for the weekend, then back to DC yesterday, and off to Denver today. Between that and keeping the Oval Office at over 80° what's his carbon footprint? How come only us peons have to conserve?
Monday, February 16, 2009
I'm having fun on twitter, under my real name, NancyGilly.
Primarily following #tcot. It's nice to know that I'm not the only one thinking torches and pitchforks, or at least tar and feathers.
Primarily following #tcot. It's nice to know that I'm not the only one thinking torches and pitchforks, or at least tar and feathers.
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