Health for life

Lets choose the health insurance channel!

A running joke among many managed care medical directors is that the typical enrollee spends hours comparing features and prices for their flat screen TVs and minutes selecting their health insurance.  Far too often, its after enrollees get sick that they discover that many of their assumptions arent meeting the reality of the provider network, coverage exclusions and out-of-pocket expenses that they chose. 

Whats more, juicy anecdotes of failed enrollee expectations (such as unproven cancer treatments in cute bald children) have fueled advocates demands for a generous version of orm (such as a single payer with a rich one-size-fits-all benefit design).

Thats why the Disease Management Care Blog found this Kaiser Health News report interesting.  It raises two issues.

1. The Merits of Consumer Shopping.

According to the KHN report, what were reading elsewhere isnt quite true because users of Massachesetts health insurance exchange (HIE) are being flummoxed by a thicket of multiple insurance options with premiums that vary according to provider tiers (some hospitals will cost you more), out of pocket expenses (a.k.a "skin in the game" stuff like co-pays and co-insurance) and exclusions (some things are not covered).  As a result, a shopper can expect to spend "six to eight hours" selecting a plan!

The DMCB is shocked, shocked by the specter of consumers having to spend as much time comparison-shopping for health insurance as the typical amount of time used checking out Consumer Reports, scanning the newspapers for sales, seeing if Amazon has a better deal and driving to several electronics stores for that best flat screen, Blu-Ray player or speaker system.  Dammit, says the DMCB, buying health insurance is important and it deserves that much time.  If an HIE forces consumers to finally pay attention, the DMCB says that is a good thing.

As an aside, the DMCB also points out that the art and science of HIEs are still evolving.  With better informatics and user-friendly on-screen interfaces, it should get better.  Given governments heavy hand, however, the DMCB predicts HIEs will never match the astonishing slickness of parallel on-line consumer purchasing aids, such as smart iPhone apps.  Taxpayer consumer expectations will continue to not be exceeded.  They will be eventually met, however.

That being said, however, the Massachusetts experience also speaks to the naive assumptions underlying the Affordable Care Acts HIE provisions.  If that remains problematic, consumers will always have the option of letting D.C.s Pete Stark, Max Baucus and Kathleen Sebelius save them time by arranging the details of their insurance for them.

2. Anecdotes and Framing

The underlying tone of the KHN piece vaguely suggests that consumerism and health insurance is a bad thing.  From the typical use of a selected negative anecdote, the skeptical visage of the person featured in the article, a "I could not figure it out" sub-headline, the sub-text portrayal of insurers as being intentionally opaque and the prominence given to saving money all paint a picture of a system that is failing. 

Good grief, HIEs have just gotten out of the crib and KHNs reporting suggests that the liberal and progressives still want to strangle this toddler.  Once again, the DMCB is shocked... shocked.

According to the White House, the health insurance exchange glitches are a symptom of high demand from a grateful citizenry eager to embrace Obamacare. While articles like this and this suggest that sloppy and amateurish programming is really behind the website crashes, the Disease Management Care Blog is concerned that early high demand - if it exists - could be an early sign of a coming insurance death spiral.

"Death spirals" occur when persons with high levels of risk disproportionately enter an insured population.  When that happens, premiums have to rise to match the increased expenses. That, in turn, causes persons with lower risk to drop their insurance, leading to an even higher proportion of high risk individuals, who drive prices even higher.

The DMCB intuitively doubts that the early high demand described by the White House is the result of healthy latte-sipping millenials and young invincibles having nothing better to do with their web-surfing time.  Rather, the persons most likely to be in a rush to get into the web site are persons who really need insurance.  Those would be the ones facing huge health care bills.
 
Another indication is the relative lack of the standard individual anecdote or "ledes" in media reports that hook the reader into paying attention.  Used by politicians and journalists alike, ledes put a "human face" on a narrative by bridging the personal and the policy.   

Supporters of exchanges would probably like to see something ledes along the lines of...

For years, 25 year old Ivanna Ceeadoc could only lurk outside the local health clinic and watch helplessly as her friends from the coffee shop down the street got free health communications from the nurse practitioners within.  But after using the health insurance exchange....

or

Until he signed up in the health insurance exchange, part-time jazz drummer and retail specialist Hank Erinfersumburgers never had to see a health care provider. Previously unaware of a bleak future of fast food and tight clothes, Hanks zero dollar co-pay now lets him see a dietician and have enough money left over for a lunch......

Young Ivanna and Hank havent made an appearance in the national health insurance exchange narrative because they probably arent part of the story.  More likely, its persons in their 50s and early 60s who have been hold they need a joint replacement, an angioplasty or back surgery....

 Ima Medeesazter was looking at a stack of medical bills a mile high.  Her surgeons plans included weeks in a hospital costing her hundreds of thousands of dollars. Ima put things off, but now that she used the exchange, she can look forward to getting to know her ICU nurses really well.......

Even more worrisome: this astonishing statement by HHS Administrator Kathleen Sebelius that she "doesnt know" how many have enrolled in health insurance since the October 1 opening date.  If the experts running the shop are unaware the Insurance 101 principle of knowing who and why persons are signing up for health insurance, they have no idea about the spiral threat.

Image from Wikipedia

The health insurance requirements vary from state to state in USA, for example the San Diego Health Insurance requirements might be quite different from the Health Insurance requirements at Cherokee County! Hence it is important to understand the specific requirements that need to be adhered to while opting for health insurance. In this article we try to cover the requirements that the residents of California would have to look at.

It is important to note that though there are many providers of health insurance packages across the states, these packages are regulated by the individual state agencies. This article addresses the requirements of the California state that need to be looked at for San Diego Health Insurance for example. The federal arm has in place some crucial laws that have been established so as to ensure the citizen’s benefits.

· The Affordable Care Act: This law has come in to action in March 2010 and ensures that the health insurance is affordable.

· COBRA: This is directed at the ex –employees, retired citizens, spouses and other dependents. Through COBRA they have the right to obtain continuation of the group health plan for some more time. This is a good option in times of economic turbulence where people can be laid off.

· HIPAA: This provides the protection to the individual and the family when there is a need to either move to another health insurance or even to continue the current health insurance. This covers the health insurance conditions like the exclusion of pre-existing illnesses and provides the much needed protection that one needs in such cases.

There are some special provisions and funds available for the employees of federal agencies and the Armed Forces by the federal government like Medicare, Medicaid, Veterans Health Benefits etc.

There are many agencies regulating the different health insurance policies and companies available in California. The California Department of Healthcare Services manages the Medi-Cal program along with the programs directed towards children like the California’s Children Services programs etc. Similarly the California Department of Insurance is the division which ensures that effective insurance laws are established in the state of California and also provides extensive information pertaining to health insurance in the state.

There some special programs enunciated by California State for people falling under the low income group or have special needs. The Medi-Cal is one such program for the low income group and also covers health conditions like tuberculosis, HIV/ AIDS etc. Medi-Cal also has a Cancer Treatment Program for women who are diagnosed with either breast or cervical cancer and require treatment. Another low income focused insurance plan is the Healthy Families plan mainly for pre-teens and teens. This covers along with health, both oral and vision issues too for children without insurance and who do not come under the Medi-Cal scheme. Then there is the AIM scheme for expectant mothers, where the newborn infants too are covered. This is for people whose income is higher than the Medi-Cal bracket but still falls under the low income segment.

So whether you are looking for the San Diego Health Insurance schemes or the Palo Alto’s you can verify your eligibility for these schemes if you are residing in California.

Authors Resource Box

For more details about San Diego Health Insurance please visit our site. http://www.blankethealthinsurance.com/

Article Source : About California Health Insurance
Author : Cyril

Is this also some type of "mandate?"

With two prior posts under its belt ("Optics" and "Furies"), the Disease Management Care Blog continues to follow the opinionating over the constitutionality of Affordable Care Acts health insurance "mandate." The latest is this New England Journal Perspectives piece.  According to author Mr. Elhauge (who personally opposes the mandate), a federal law that uses the Commerce Clause to require persons to purchase health insurance is perfectly legal and proper at multiple levels:

Congress has repeatedly used broad interpretations of the Constitution to insert itself into the conduct of commerce, so the mandate is nothing new.  One past example is the prohibition against gender, religious or racial discrimination by private firms, while another is the ban on home grown medicinal marijuana.  Since health care is a commercial activity in the public space, the logic is that Congress can similarly require anyone who has ever received health care in the past to purchase health insurance for the future.

While prohibiting an activity (like discrimination or pot) may not be the same as requiring an activity (health insurance), readers may be interested in knowing that the first Congress not only required ship owners to buy medical insurance for merchant seamen but later required seamen to buy hospital insurance.

And what about that mortgage deduction?  If you dont buy a house, you cant take the deduction, which economically the same as a penalty for not engaging in the economic activity of home ownership.

Another favorite of mandate opponents is the argument that the Feds are on a slippery slope leading to a requirement that we all buy broccoli or General Motors cars.  The counter argument is that Medicare is a system that requires the purchase of "broccoli" at government stores.  Whats more, if we were to privatize Medicare, wouldnt that also functionally be a mandate for the purchase of private insurance?

Last but not least, if personal liberty is the underlying issue, the argument is that no one would ever force anyone to eat the broccoli.  Mandating insurance is not the same as mandating health care.

While the prescient Disease Management Care Blog was among the earliest to identify the threat of an Obamacare-induced insurance "death spiral," it missed spotting the potential fallout from a delay of the individual mandate.

As shrewdly pointed out in this Politico article, health insurance timelines require at least three months of claims experience to inform future rate setting.  Once that actuarial work is done, it then has to go through the states Insurance Departments for approval.

In other words, if large numbers of Obamacare customers are allowed to sign up after March 31, 2014, insurance companies wont know what to charge their customers on January 1, 2015. 

While overcharging can be remedied by customer rebates, it remains to be seen how accommodating Washington DC will be if the insurers undercharge. That means negative cash flows, raiding surpluses and facing the ire of their investors and Boards of Directors.

Its baseball season, so think of the death spiral as a potential strike one, and inaccurate rate setting as a potential strike two.

Which brings the DMCB to a dreaded strike three. If it happens, the health orm brand could be irretrievably tarnished.  It could also and sink the current version of Obamacare.

Strike three would be a critical mass of inaccurate insurance policies.

If reports like this and this are even remotely representative of the back-end of Obamacare enrollment, the relative trickle of individuals who are successfully navigating the exchanges are getting commercial polices that depend on a very vulnerable reconciliation process involving many moving parts.  That includes information from the "hub" as well as user-based data entry. As noted in this report, commercial insurers are being forced to manually "clean up" the information prior to issuing their exchange-generated policies.

The DMCB suspects that a "garbage in, garbage out" adage may apply. Thanks to sheer number of inputs, clean-up mistakes are going to be inevitable.  And it will get a whole lot worse if the healthcare.gov web site gets only partially fixed. 

While a few mistakes are acceptable in large risk pools, more than a few could be huge problem at three levels:

1. At a business level, where a core competency of insurance companies is to cover their enrollees and only their enrollees. Insurance companies are really good at knowing who is and who isnt insured for a covered or non-covered service with or without a variety of co-insurance arrangements.  Its more than just getting it right, it goes to the core of their business model. If enough policies are inaccurate, it could bring the finances of some smaller health insurers to their knees.

2. At national health policy-making level, where a critical mass of insured customers with premiums and subsidies mismatched to the risk could destabilize the market and distract our political leaders. Think about the customers who assume a service is covered, providers who expect to get paid accurately, balance sheets that dont lect the truth about claims expense as well as IBNR and regulators who will need to sort it all out.

3. At an Obamacare "brand" level.  Think about all those unfriendly and anecdotal news reports about vulnerable patients who ended up legitimately - if mistakenly - paying more out of pocket for care, or persons mysteriously lacking insurance, or hospitals and doctors being unable to get paid. It could ultimately track back to the HealthCare.gov web site that everyone will loves to hate.

The worst part is that the White House has done such a masterful job of bullying the insurers that its unlikely that theyll want to rock the boat by going public with any notification that their enrollment data is corrupted.  Mr. Obama will naturally claim that he wasnt in the loop and his loyal aides will deflect blame elsewhere.

Strike three, and we may not even see it coming.

While the Governors Mansion in Pennsylvania is currently under the control of the Republicans, the Disease Management Care Blog knows the states Insurance Department is relatively apolitical. Thats why this September statement by Pennsylvania Commissioner Consedine before the U.S. House Ways and Means Subcommittee on Health is quite telling. 

In it, Mr. Consedine describes how the Keystone state is encountering difficulties implementing an health insurance exchange. As DMCB readers will recall, exchanges are a key feature of the Affordable Care Act, because theyll provide an online market that will enable individuals to obtain coverage.

According to Mr Consedine, CMS is failing to support a good law with the many regulatory details that turn a vague idea into a functioning reality. These failings include:

1. "Interim," not "final" rules on eligibility, tax credit calculations, cost sharing and the role of brokers

2. Little formal guidance on the determination of the essential health benefit.

3. Delays in issuance of regulations on how states and Uncle Sam will split or mutually indemnify the myriad costs of the exchange and the Federal Data Hub.

4. Delays in the issuance of regulations on how states can exit a federally run exchange to set up one of their own.

5. Lack of clarification of CMS impact on insurance markets operating outside the exchanges.

6. Little understanding of whos in charge of consumer protection statutes.

7. Confusion over reconciliation of multiple states insurance laws and regulations in multi-state exchanges.

8. No guidance on how to roll long-extablished and well functioning state-subsidized insurance programs into the exchanges.

9. Concern that funding of the information technology could be clawed back if Medicaid eligibility does not meet CMS criteria.

10. Little guidance on whether exchanges will need to provide consumers with a list of providers who are accepting new patients.

The concerns are also damning in the context of the the normal tug of war between the states and Washington DC. Thats because in his testimony, Mr. Consedine states he wrote to HHS weeks ago and has not received a reply.  While its not unusual for the Feds to stiff politically inconvenient inquiries, the Disease Management Care Blog is fearful that the reason why HHS seems unwilling to provide a timely reply is because it doesnt know the answers.

If Pennsylvanias experience is typical, that means the roll out of the exchanges could be significantly delayed.

You read it here first.

9/26/12 Update: Senator Hatch agrees with the DMCB

This isnt exactly what I wanted to write about, tonight. Im not exactly an "on-schedule" blogger, but I know this is definitely not what I was expecting to write about, tonight.

[Before I proceed, though... I just want to say that I dont want ANY pity. No pity... No feeling sorry for me... No hurting for my circumstances. No advice on what I could have done better (I will rip you a new one, if you do, just be forewarned). Life is what it is, and we are all dealt... what we are dealt, sometimes. Whatever that is. There are people, right now, going through a LOT more difficult circumstances. They deserve our support... so dont you worry about me. Also, this post might have a lot of swearing.]

I just need to process, and I need to vent. So to heck with it.

... Where do I start, I dont know. Its such a blur,  now.

Last Sunday.

Last Sunday, running my hands through my hair, while wanting to put it up in a clasp, I found a large, swollen lump or area on the upper right side above the nape of my neck. It wasnt entirely dissimilar to the one on my left side, but distinctly swollen feeling, and sore if one put gentle pressure on it... and irradiating discomfort.

Of course, being The Angry Type 2 Diabetic that I am, I freaked out... said a few choice phrases rhyming with "What the fructose??" and sort of felt the clammy feel of panic rising up my spine. (You never want to feel that kind of panic when you have no insurance.)

I decided, though... that I was going to remain calm. (HA!) Just monitor it for the week, and wait until Thursday (today), for the Free Clinic, to get it checked out. As things sometimes go, I started feeling... unwell.  "Woozy," feverish... just uncomfortable from the growing pressure in that area of my head... The "soreness" was starting to radiate down to my right shoulder, down my neck... And today, well, it was just difficult to focus, at work, and I noticed I couldnt really walk a good distance without feeling... just weird. Light-headed. Nauseated. "Its okay, though," I thought... "Today is the Free Clinic, and theyll have a look at it."

Now, the Free Clinic in my town is basically a rat pack of some medical professionals of various ilks who volunteer to provide some basic/minimal health care to uninsured people, no questions asked, and which only generally meets on Thursday evenings, from 6-8 pm. You have to arrive at 4 pm, though, and make quite the long line. Waiting for care often averages between 4-6 hours... and its first come first served, of course. They can only see about 15 people.

The problem is... they used to have a somewhat permanent building, which has since been torn down by their tenant -- the next door church, while they make some new additions and changes to their facilities. So, the Free Clinic now has to share space with the next door church, and can only meet whenever the heck the church is not having some event. Which basically means... whenever a magic 8-ball decides.

I walk out there... just praying, praying under my breath that they are meeting. Lo and behold, as Murphys Law loves me so much... They are not meeting. I think its because of some stupid Pancake Day crap. I dont know. (Insert your personal sensibilities approved curses here.)

Then you have to make the tough decisions. Is this something that you think will go away; get better on its own? Am I overreacting? Is this... something that... could potentially get worse very quickly, and kill someone? Is this something that can be stopped, but it just needs immediate attention? I dont know... Do I go to the ER (because the local medical clinic is closed... and, even if it was open, they wont see me because I have no insurance and a hefty past medical bill that I cant prioritize to pay right now (dont judge me... you dont know me... and they wont let me pay anything less than an outrageous amount, every month...), while so underemployed and on food stamps...)? Or do I chance it?

Reluctantly, I decide... Im going to go to the ER. I dont want to be the freak on tomorrows front cover story that died within days, from something simple, or who knows what. The worst they can do is turn me away. And I was wrong. The worst they can do is shame me, while turning me away.

The doctor didnt even really look, or touch the area much. He basically pushed my hair around, said it looked exactly like the left side of my head, that he didnt see any physical injuries, and then asked have I ever cared to examine the left side of my head...

(Yes, doctor, the rest of us who arent doctors are certainly idiots... We go entire lifetimes NOT touching our own bodies.)

....and then proceeded to tell me it was probably just me being worried about it, or at the very most a resented lymph node. He dismissed my other symptoms with the wave of a hand, gave me a smirk and a suppressed laugh, and said that I need to just let it stay like that, and come back in a week if it got much worse (with big disbelief all over his face).

I tried, very unsuccessfully to get his attention. He just basically acted like I was bullshitting him, and walked off.

Nurse Patronizer walks in. Nurse Patronizer notices Im quite angry. I dont recall whatever tipped it off... (pffft!) But... Nurse Patronizer says to me "I dont know what you two discussed," and boy do I let the flood gates go... and I start crying, right there. She begs me to give her 5 minutes and goes off, basically to talk to Full of Himself Doctor, who says "Oh, she needs to just watch the area for 2 or 3 days (yeah, rather than a week, like he had said before... hmmm)..."

Nurse Patronizer repeated over and over again how it wasnt that I had no insurance, while at the same time pushing a flyer on me to go to the Free Clinic tonight.... After I had spent a good chunk of time explaining to them that the Free Clinic was closed. They wouldnt believe me, and kept asking me *why* it was closed. Now how in the &#$@ should *I* know?! All they had was a sign posted about "We will have No Free Clinic Tonight, 03/01/2012." Im not their schedule keepers!

So, really... hmmm... If you are not punishing me for not having insurance, then perhaps you were punishing me for your perceived notion that Im using the ER as a PCP providers office, and not waiting until whenever the heck THEY would have given me an appointment (should I had been able to get one, which I know from experience, that I would have not, because of my outstanding bill. I know how those jerks work, too.)

So, off they sent me... With apparently, a few "lessons" for the road:

• Youve lived with your body for 35 years... and are quite educated, Liz, but you dont know your own head;
• You have no insurance, and are underemployed, so you must be subhuman, or some mentally unstable person making stuff up... abusing our services;
• You are nothing more than money;
• I hope you dont die, but good luck. Suck it up, butter cup.

"Gotcha!"

Years ago, the Disease Management Care Blog proudly showed the consulting health insurance actuaries published data like these and these. It naively expected the actuaries to agree that disease management had resulted in cost reductions and that the programs should be favorably factored into the managed care insurance plans premium pricing for the coming year.

The response of the actuaries was "no."

Disease management not only did not factor into their trend analysis, they decreed that the programs costs needed to be loaded as an additional administrative cost. The worst part of dealing with their obstreperous math was that the health insurance plan was actually paying them to deliver this bad news.

Which is why the DMCB believes that anyone who believes that actuaries relationships with health insurers are riddled with conflicts of interest is amateurishly misinformed.  To wit, Senator Franken (D-MN) recently scored a political "gotcha"against the Society of Actuaries when they had the temerity to predict that health insurance costs in the individual market could go up by 32%. While it is true that their consulting services generate fees that are paid by their insurers, their hard-nosed recommendations are hardly ever welcome in the industry, their fees are not linked to health plan profitability, states have regulated actuarial consulting input for decades and, to add insult to injury, customers like the DMCB have to pay their fees for unwanted news.

At one level, the DMCB welcomes members of the U.S. Congress to its world.  The job of the independent actuaries is to present inconvenient truths about future health care trends and premium pricing.  At another level, the DMCB is concerned that Frankenesque-style bluster and bullying could force health insurance actuaries to underprice insurance and destabilize the market just when Obamacare is getting out of the blocks.  We deserve better.