“Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul. But consumer advocates warn that companies are still using wiggle room to discourage the sickest — and costliest — patients from enrolling.
Some insurers are excluding well-known cancer centers from the list of providers they cover under a plan; requiring patients to make large, initial payments for HIV medications; or delaying participation in public insurance exchanges created by the overhaul.
Advocates and industry insiders say these practices may dissuade the neediest from signing up and make it likelier that the customers these insurers do serve will be healthier — and less expensive.
“It’s the same insurance companies that are up to the same strategies: Take in as much premium as possible and pay out as little as possible,” said Jerry Flanagan, an attorney with the advocacy group Consumer Watchdog.”
“Bill Jacobs spent four nights in a hospital in Florida battling pneumonia. His kids visited each day, fluffed his pillows, brought his favorite Sudoku puzzles and got regular updates from his nurses and doctors. Imagine their surprise when they found out that their 86-year-old father was never actually admitted; instead, he was treated as an outpatient under what Medicare refers to as “observation status.”
What difference does that make? Actually, more than you might think. If your parents are on Medicare, the difference between being considered an inpatient or an observation patient could be thousands of dollars out of their pocket, if not more.
First, Medicare Part A will cover all hospital services, less the deductible, but only if you’re admitted to the hospital as an inpatient. The one-time deductible covers all hospital services for the first 60 days in the hospital. Doctors’ charges are covered under Medicare Part B. After you meet the deductible for Part B, you’ll then owe 20 percent of the Medicare-approved amount for doctor services, according to the Centers for Medicare and Medicaid Services’ Are You A Hospital Inpatient Or Outpatient?”
“Every day in intensive care units across the country, patients get aggressive, expensive treatment their caregivers know is not going to save their lives or make them better.
California researchers now report this so-called “futile” care has a hidden price: It’s crowding out other patients who could otherwise survive, recover and get back to living their lives.
Their study, in Critical Care Medicine, shows that patients who could benefit from intensive care in UCLA’s teaching hospital are having to wait hours and even days in the emergency room and in nearby community hospitals because ICU beds are occupied by patients receiving futile care. Some patients die waiting.
On one day out of every six, the researchers found, UCLA’s intensive care units contain at least one patient receiving useless care while other patients are unable to get into the ICU.
More than half the time, over a three-month period the researchers examined, the hospital’s intensive care units had a least one patient receiving futile care. The study shows the ripple effects of that futile care within the UCLA hospital and in surrounding hospitals where patients were waiting to be transferred.
“It is unjust when a patient is unable to access intensive care because ICU beds are occupied by patients who cannot benefit,” the authors write.
“The ethic of ‘first come, first served,’” they say, “is not only inefficient and wasteful, but it is contrary to medicine’s responsibility to apply health care resources to best serve society.””
“File this under ‘how ironic.’
Drug makers are asking for more transparency from the government agency that is requiring them to be more transparent about how much they pay doctors.
The Pharmaceutical Research and Manufacturers of America, or PhRMA, is calling on the Centers for Medicare and Medicaid Services to further explain why the agency has removed one-third of the payment information from an online database that is due to be made public by Sept. 30.
Earlier this month, CMS said it would withhold about one-third of the payment data from the so-called “Open Payments” system. The agency also said it would return the records to drug makers because they were “intermingled,” including the erroneous linking of payment information for some doctors to still other doctors with similar names. CMS cited incorrect state medical-license numbers as one reason for the mix-up, among others.
CMS had collected partial-year 2013 payment data from the companies and began allowing doctors to go online for a preview this summer, before the database goes public by Sept. 30, in order to dispute any inaccuracies. But CMS closed the preview function for about 11 days to investigate the data intermingling and re-opened the site nearly two weeks ago. The missing one-third will be put back in the database at a later date, likely next year.”
“Middle Tennessee State University (MTSU) is restricting student work because of compliance issues associated with the Affordable Care Act (ACA), commonly known as Obamacare.
In an email last week, MTSU President Sidney McPhee explained that “due to our interpretation of the reporting requirements of ACA,” graduate assistants, adjunct faculty members, and resident assistants are barred from working on-campus jobs that exceed 29 hours of work per week.
“[E]ffective beginning with the fall semester, we will no longer allow part-time employees, or those receiving monthly stipends from the university, to accept multiple work assignments on campus.” Tweet This
Now, they cannot take on multiple campus jobs.
“[E]ffective beginning with the fall semester, we will no longer allow part-time employees, or those receiving monthly stipends from the university, to accept multiple work assignments on campus,” the email stated.
McPhee noted that violations of the law “could add up as high as $6 million” in penalties.”
“Responding to ongoing problems at the Washington Healthplanfinder insurance exchange, state Insurance Commissioner Mike Kreidler on Monday instituted a limited special enrollment period for consumers who want to obtain coverage outside the exchange.
From Aug. 27 to Nov. 14, those who have had problems with enrolling or making payments through Healthplanfinder can enroll in coverage outside the exchange either by selecting a different plan with the same carrier or by changing carriers.
“This is a problem that has been around since the end of December,” Kreidler said in an interview. “I am cautiously optimistic that the exchange is doing a much better job right now to resolve the problems, but there is no guarantee that they’re going to be gone as we go into open enrollment.””
“When she was eight weeks old, Ashlyn Whitney suffered a severe respiratory-tract infection that put her in an intensive care unit for 12 days.
“Because she was so young, she couldn’t handle it,” Ashlyn’s mother, Nicole Whitney, recalled. “They had to give her oxygen.”
The baby, now a year old, recovered from her illness, known as respiratory syncytial virus.The bill for her treatment at the West Boca Medical Center in Palm Beach County came to about $100,000 — a sum that included almost $4,000 in fees for her birth and pre- and post-natal care — but every dime of the tab was picked up by a medical bill-sharing organization set up for its Christian membership.
Such religious groups are exempt from the Affordable Care Act’s mandate that most Americans obtain health insurance or pay a penalty. Although as many as 30 million Americans will remain without health insurance by 2016, despite the best efforts of the ACA’s proponents, all but about seven million of them will be spared having to join the new system because of exemptions created by the act itself, according to an analysis by the Congressional Budget Office and the staff of the Joint Committee on Taxation.”
“Devin Payne had gone years without health insurance – having little need and not much money to pay for it.
Then Payne, who had a wife and four children, realized she could no longer live as a man.
In her early 40s, she changed her name, began wearing long skirts and grew out her sandy blond hair. And she started taking female hormones, which caused her breasts to develop and the muscle mass on her 6-foot one-inch frame to shrink.
The next step was gender reassignment surgery. For that, Payne, who is now 44, said she needed health coverage. “It is not a simple, easy, magical surgery,” said Payne, a photographer who lives in Palm Springs. “Trying to do this without insurance is a big risk. Things can go wrong … not having the money to pay for it would be awful.”
Payne learned in the fall that she might qualify for subsidies through the state’s new insurance marketplace, Covered California, because her income fell under the limit of $46,000 a year. She eagerly signed up in March for a Blue Shield plan for about $230 a month, and began making preparations for the surgery that would change her life.”
“As more Americans gain insurance under the federal health law, hospitals are rethinking their charity programs, with some scaling back help for those who could have signed up for coverage but didn’t.
The move is prompted by concerns that offering free or discounted care to low-income, uninsured patients might dissuade them from getting government-subsidized coverage. It also reflects hospitals’ strong financial interest in having more patients covered by insurance as the federal government makes big cuts in funding for uncompensated care.
If a patient is eligible to purchase subsidized coverage through the law’s online marketplaces but doesn’t sign up, should hospitals “provide charity care on the same level of generosity as they were previously?” asks Peter Cunningham, a health policy expert at Virginia Commonwealth University.
Most hospitals are still wrestling with that question, but a few have changed their programs, Cunningham says.”
“Listing to a panel discussion sponsored by the Greensboro Chamber of Commerce Tuesday morning, I heard reference to a metaphor for the Affordable Care Act that I’ve heard a number of time before — the three-legged stool.
Describing the different core components of the health care reform law, three primary tenets offer their support to the law, with, each complementing and reliant upon the others, and the stool falling over if one of the legs falters.
They are: guaranteed issue and community rating (meaning an insurer can’t deny coverage or charge astronomical rates coverage because of pre-existing conditions), the individual mandate (everyone must have coverage or face a fine) and subsidies (financial assistance from the federal government to help low-income consumers can pay for coverage).
I’ve sat in on numerous, similar discussions, and had heard the metaphor before. But it wasn’t until comments from panelist Mark Hall, a professor at Wake Forest University School of Law and a leading health care policy scholar specializing in health care reform, that I realized I was missing a key part of that image.
Those are the three legs — what’s the seat represent?
As Hall noted, if you go by what the law is called, the “Affordable Care” Act, you’d be mistaken.
“One thing it doesn’t do is it doesn’t make care more affordable,” Hall said said during the discussion, which was organized by Pilot Benefits. “Mistake number one was to call it that. It doesn’t change in any significant way how doctors and hospitals are paid.”
As Hall noted, while many opponents might criticize the bill for not reducing health care spending, “the main point is it does not affect how health care is delivered or paid for. … That point is lost on about half of the population.'”