Buy the DVD: www.shoppbs.org BMJL4306_052209:N:DGR:N:N:609:QPBS Washington’s abuzz about health care, but why isn’t a single-payer plan an option on the table? Public Citizen’s Dr. Sidney Wolfe and Physicians for a National Health Program’s Dr. David Himmelstein on the political and logistical feasibility of health care reform.

For the last couple decades our country has faced a huge problem that has been getting bigger every year, health care. The cost of insurance has spiraled out of control to the point where companies can no longer afford to offer benefits and the average individual can’t pay the premiums. A family would have to pay hundreds a month, in many cases more than rent, making it the largest expense they face. The insurance industry has made moves to save themselves money, but it sure doesn’t seem that those savings are being passed on and the medical profession hasn’t shown any interest in making their services less expensive.

Medical insurance is a big issue every election year and we hear stories on the news all the time, but remedies never go past talk. It is estimated that 7 out of 10 Americans are either under insured or completely uninsured leaving us in a crisis. Our country has the best medical care in the world available, but millions of people are putting off doctor visits and procedures simply because they can’t afford the bill. Not only does this effect a persons quality of life in the short term but also can lead to much bigger, more expensive problems in the future. I know because I was one of these people. After years of putting things off because I could hardly pay the bills I already had, my health started to deteriorate. The bills were going to be bigger than they would have been several years before but if I took care of things at that time I could be facing a large debt.

In 1948 President Truman made the first push for universal health care in our country. Since that time It has been used as a campaign promise & attempts have been made to make national health coverage a reality, but very few bills ever even make it out of committee. The truth is that if you are waiting for our government to fix the problem you could be waiting for a very long time. I believe that if a real solution is to come it wont be from Washington but from a private company that finds a way to develop a plan the millions of uninsured Americans can afford. Personally I feel the private sector would do a better job than Uncle Sam. Our Government has a reputation for creating large, inefficient bureaucracies that fall short of expectations and cost more than predicted. A private company has to survive but also offer a good product people can afford.
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Barack Obama’s ambitious health care plan is fairly simple and straightforward. His plan seeks to dramatically and swiftly increase the number of people that have health insurance. He insists that this plan will save the typical American family approximately $2500 in annual costs. Since the average Ohio premium is less than most other states, savings to Ohio residents may average less than $2500.

The plan is designed to give the federal government more control over medical decisions and dollars, a major difference from the current decentralized system of employer-based insurance and state-based insurance regulation. Here in Ohio, health insurers have been effectively held in check by the Ohio Department of Insurance. This, however, is not the case in many other states.

The Obama Plan

Many parts of the Obama plan resemble initiatives from the Clinton health plan of 1994 and the Kerry Health plan of 2004.
Essentially, Obama’s health care plan is divided into three sections:

1. Modernizing the US health care system to lower costs and improve quality
2. Promoting prevention and strengthening public health
3. Quality, portable and affordable health coverage for every person

The “Savings”

The $2500 in savings will come from health care reform, using some of the following initiatives:

*Making medical insurance universal, which may reduce spending on uncompensated care.
*Improving management and prevention of chronic conditions.
*Increasing insurance industry competition and reducing underwriting costs and profits.
*Providing reinsurance for catastrophic coverage, which will reduce insurance premiums.

Shifting Cost Burden

While all of these ideas are feasible, the underlying theme seems to be simply shifting some of the cost burden from the private sector to the government. And of course, much more control of our health dollars and decisions would come from Washington D.C and not Anthem or UnitedHealthCare.

The plan will actually compete directly with Ohio private insurance companies in a “National Health Insurance Exchange.” The federal government (not health insurance carriers) would determine the quality of benefits that Americans would receive. And these new rules would apply to both the new national health plan and all participating private health plans.

Preventative Coverage Would Be Emphasized

Obama’s health care plan will encourage “healthy lifestyles” with specific emphasis on wellness. Employer wellness programs will be increased, and cafeterias and vending machines in the workplace may see healthier food.

School-based health screening programs may increase along with increased support for physical education.

For Ohio individuals and families, the Obama plan would require preventative services on many federally-supported programs such as Medicare, Medicaid and SCHIP. One benefit may be possible discounts to on health insurance premiums for enrollment in wellness and prevention programs.

Currently, some Ohio individual health insurance policies offer a similar discount, such as Anthem’s Lumenos Health Incentive Account (HIA).

Ohio Group Health Insurance

Employer-based health insurance would radically change under the Obama plan. Here in Ohio, both small and large employers are able to choose among many different plans for their employees. The Obama plan would force employers to offer a specific level of health benefits to their employees or pay a tax to finance a national health program. Currently, the amount of provided health benefits and the size of the tax have not been specifically discussed.

Perhaps the best and most economical health insurance plan for Ohio residents would be a concept already in place…HSAs (Health Savings Accounts). Thus, instead of imposing a top-down change on the health care system, it would seem to be prudent to transfer direct control of medical dollars to individuals and families. This would allow Americans to choose their own health plans and benefits, while making health insurance companies compete directly for consumer’s dollars by providing a real value to patients.

All of this could be accomplished by specific tax and regulatory changes designed to utilize the power of free-market competition. Health care spending could be reduced, preventative treatment could be emphasized and portability could be promoted. Reforming the tax treatment of health insurance and aiding employers that help their employees buy health insurance would help quite a bit.

For now, Ohio health insurance rates are remarkably low compared to many other states. There are many reputable insurance companies that offer a wide array of policies, including Health Savings Accounts. That shouldn’t change much for the next two years. In 2011, things might change…hopefully, for the better.
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The state of Colorado has approved a move by Anthem Blue Cross Blue Shield to keep rates for its Medicare Supplement plans the same in 2010 as they were in 2009. Accordingly, there will be no rate change for Anthem Medicare Supplement plans available in Colorado. However, Anthem Blue Cross Blue Shield does remind customers that there is no rate guarantee for new businesses.

More information about rate adjustments

Rate adjustments for Medicare plans are common and are seen as necessary by health insurance providers for several reasons. One of the most common reasons for rate adjustments has to do with the increase in deductibles and coinsurance amounts from the Center for Medicare and Medicaid Services.

CMS increased the Medicare Part A deductible from $1,068 to $1,100. Part A coinsurance amounts increased from $267 to $275 per day for hospital stays from the 61st day in the hospital through the 90th day in the hospital. The coinsurance rate increase from $534 to $550 per day for the 60 lifetime reserve day. Also, coinsurance for Skilled Nursing Facility Care increased from $133.50 per day to $137.50 per day for days 21 through 100.

There were also changes to Medicare Part B deductibles; the deductible amount will increase from $135 to $155 per month and the premium rate will increase from $96.40 to $110.50 per month. There will be no corresponding increase in Social Security benefits in 2010 to help cover the cost of the increased rates. Also, based on income filing status, the CMS has set a higher Medicare Part B premium rate for higher-income participants and couples.

Again, Anthem Blue Cross Blue Shield subscribers may have the same rates because of Anthem’s choice to forgo the rate increase.

According to Blue Cross Blue Shield, instead of increasing cost of coinsurance and deductibles to customers, Anthem Blue Cross Blue Shield plans will cover these increases as long as the plan already covers deductibles and coinsurance amounts. As a result, the amount of money that Anthem pays out to health care providers in benefits for its participating members will increase.

Another reason that many rates for health insurance plans increase is become of the increased cost in providing health care services. This cost correlates to an increase in the number of Medicare beneficiaries who also enroll in Medicare Supplemental insurance plans. According to Anthem Blue Cross Blue Shield, the health insurance provider received the cost and use of its Medicare Supplemental insurance benefits and determined that they do not need to change the premiums for the plans for Colorado residents yet. The move to keep the rates the same as they were in 2009 will help to save Anthem Medicare Supplemental insurance plan members money.

Medicare Supplemental insurance helps to cover the doughnut hole coverage gap that applies to many individuals enrolled in traditional Medicare plans. With Supplemental insurance, participants can have increased coverage even when traditional Medicare plans do not provide adequate coverage for their healthcare services or products. Medicare beneficiaries should work with an experienced Medicare advisor to learn more about which Medicare Supplemental insurance plans are right for them.

President Obama’s plan for reforming health care contains some surprising provisions. One is QUALY, which stands for quality adjusted life years. The more I hear about QUALY, the more I feel like a throw-away person. When you first hear the term, it sounds good, and you think doctors are going to do all they can to extend your life.

That is not what the implementation of QUALY would be. Yes, doctors would do all they can to extend your life, but their actions would be limited by government regulations. What is QUALY? It’s a mathematical formula that determines whether senior citizens receive health care or not. The British health care system has QUALY. “Bandolier,” an independent British publication about evidence-based health care, takes exception to the formula idea.

According to the newsletter, the idea of adjusting life years was created to “combine the quantity and quality of life.” While this sounds like a good idea, the Oxford scientists who write the newsletter — Andrea Moore, Sheena Derry, and Maura Moore — say QUALY is a crude measurement with serious flaws.

“QUALYs have been criticized because there is an implication that some patients will be refused or not offered treatment for the sake of other patients,” they note.

A Health and Quality of Life Outcomes Website article, “Problems and Solutions in Calculating Quality-Adjusted Life Years,” details complex, new formulas for determining QUALYs. According to the article, these formulas are based on utility and time, but “quality (utility) and quantity (time) of life are of essentially different data-types and cannot be combined by a simple product of their numerical values.”

I’m a senior citizen and think portraying my life, and the lives of other seniors, as a mathematical formula is an insult. This formula discounts the education, experience, and wisdom of senior citizens. Seniors contribute to American society in countless ways. Many continue to work long into their 70s. Others volunteer in their communities. Thousands of senior citizens like me are raising their grandchildren.

The fact that congress would be exempt from HR3200 and the QUALY provision is also an insult. If this health care plan is so stellar, congress women and men should be on it, too. While I can’t speak for all senior citizens, I can speak for myself, and need a health care bill that:
* assures my access to quality health care,
* doesn’t ration care,
* lets me choose my doctor,
* gives me insurance options,
* continues Medicare and Tri-care (military) coverage,
* does not call for quality adjusted life years
* and provides fair reimbursement for value of service.

Mayo Clinic endorses these provisions. According to a Rochester, Minnesota “Post-Bulletin” article, “Mayo Refocuses on Health Reform,” Mayo does not support the so-called public option for health insurance. “We do not support the creation of another government-run, government price-controlled, Medicare-like insurance plan,” states Mayo.

However, Mayo Clinic is in favor of legislation that requires Americans to buy health insurance, sliding-scale subsidies for those in need, and defining a minimum health care benefit package. QUALY is not a health care benefit, it is a health care penalty for senior citizens who worked hard and helped to make this country great. We all get older, so say no QUALY today, for it could harm you tomorrow.

Copyright 2009 by Harriet Hodgson
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Modern day medical care can work miracles, but how can you afford it? How do you know which plan will cover you in case of emergency? Here’s a few ways to help you find affordable personal health care insurance:

Personal Health Care Insurance Plans

A lot of people don’t have health care benefits because it’s either not provided by their employer or they’re self employed. To get health insurance they have to purchase their own personal health care policy. If you fall into this category, then you should learn as much as you can about the various health care plans before buying your own policy.

There are many things which affect the cost of your health care premiums. The amount of your deductible plays a large part in determining the cost of a health insurance policy. A deductible is the amount of money you pay towards your medical costs before the insurance company begins to pay. A larger deductible will get you a lower monthly premium.

Copayments are another way to keep insurance premiums as low as possible. A copayment is a fee you pay each time you visit the doctor or hospital. A typical copay amount with a managed health care plan such as an HMO or PPO is $15 to $20 per visit. Managed care health plans offer quality medical care at reduced costs.

Personal Health Care Insurance Quotes

One of the best ways to find affordable health insurance quotes is to go to a free insurance quote website. There you can get competitive quotes from up to 5 health insurance providers so you can compare plans and prices. After you have your quotes, you can look more closely at the policies and decide which one is the best for you.
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When it comes to health care ethical issues, there are almost as many ethical issues as there are health issues to be treated. There are laws in place to direct the behavior of almost every person in the health care personnel chain, from the nurse to the nurses aide who assists them and the doctor who ultimately gets to try and make the decisions to treat within the confines of the insurance system ruling over the life of the patient in question.

There are ethical issues that are clearly defined, such as the requirements for treatment decisions when a patient has a Medical Power of Attorney or a Living Will. Then there are thealth care ethical issues that don’t have such clearly defined areas, such as whether it is allowable to withhold a possible lifesaving treatment from a patient only because their insurance will not pay for it.

Health care providers must make their treatment decisions based on a great many determining factors, perhaps the most constraining of which is the insurance reimbursement regime. If doctors and other health care providers could just treat their patients and have only that to worry about, what a wonderful world it would be. But doctors have to constantly worry about whether or not they and possibly the facility where they practice will be paid by the insurance companies. The next most important factor which affects health care providers ability to provide the care patients truly need is whether or not the patient has been truthful with the information they have given to the health care provider, and whether or not they have had access to health care to establish and maintain their health care needs.

Ethical concerns also come into play with patients whose family constellations are unclear. A patient who has a spouse has a straightforward next of kin when decisions have to be made. When a patient is separated from their spouse, and even perhaps has a new significant other, the next of kin can be much more difficult to determine, and protecting all health care providers-doctors, hospitals, etc from the liability risk of allowing the person who does not have a legal right to make decisions for a patient is a necessity. The health care ethical issues presented by these kinds of situations are very delicate.

One important ethical concern in health care is the need to protect oneself from the very real danger of the transmission of communicable diseases in bodily fluids. Especially in cases where a patients history is not available, health care providers have the right and the responsibility to protect themselves from viruses and bacteria that may be present in the body fluids of patients to which they are exposed taking care of these patients. However, this must be balanced with the possibility of making patients feel accused or uncomfortable by these same protective measures.

One last important health care ethical issues, especially in this day in age, is the protection of private, personally identifying information. Patients records used to be kept in public places where almost anyone could read them-filing pockets outside their doors, for instance. This kind of situation is not longer allowed, and records are more closely guarded nowadays, and many hospitals now rely on records kept entirely on computers.

Ethical issues are a part of almost every field, but health care has a special place in the system, where people are trusted with making those who are sick feel better, those who are injured able to return to their prior lives, and those who have chronic conditions and those who love them more able to cope with the demands of living with those conditions.
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No doubt about it. One of the biggest coding challenges in 2010 will be how to code consults – or what used to be consults. Hospital inpatient visits will be especially tricky.

But don’t worry. My Coding Career has consulted the experts to gather these 10 best practices for consult coding in 2010.

The background: Medicare has scrapped consultation codes, and in 2010 will no longer accept codes from CPT’s 99241-99255 section. So, when you’re billing Medicare, you’ll have to find other codes to describe what used to be consults. Meanwhile, some non-Medicare payers will continue to accept consultation codes.

Here are 10 steps you can take to get paid and stay compliant:

1. Expect some larger payers to ditch consult codes as well. Some larger private payers (such as Blue Cross Blue Shield, Aetna, and Humana) will follow Medicare’s lead and won’t accept consult codes in 2010, experts predict.

2. Check with your payers. Some payers will continue to accept consult codes. Payers will announce their consult code policies by mid-December.

Tip for executing #1 & #2: Keep a spreadsheet to track each of your payers’ 2010 consult code policies, and be sure to document their instructions.

Next, what about Medicaid?

3. If you bill Medicaid, check with your state for consult instructions. Just because Medicare isn’t accepting consult codes doesn’t mean things are the same for Medicaid across the board.

4. If two or more physicians see a patient during a hospital stay, make double-sure the ICD-9 codes and/or the physician notes justify the need for two or more physicians to see the patient.

5. Stop thinking of CPT 99221-99223 as ‘admit codes.’ When a physician consults a patient on his first day in the hospital, you should use an initial hospital code. More than one physician can use an initial hospital care code for the same patient, as long as you keep #4 in mind.

6. Meet modifier ‘AN.’ When billing Medicare, modifier ‘AN’ designates a doctor as the admitting physician. If no one uses the modifier, the claim will be subject to medical review, experts predict.

7. Look at time when choosing codes for hospital inpatient care you’re billing to Medicare. At the higher levels, consults’ transfer to hospital care codes will benefit your practice’s bottom line. For 99244 and 99245, you would gain approximately 30 percent in pay if you also report the prolonged services.

8. Expect reimbursement to be lower for lower-level hospital inpatient visits that would have been consults under Medicare’s old system.

9. Focus on total work when coding for split/shared inpatient visits for Medicare. You can ignore one requirement here thanks to Medicare’s invalidation of the consult codes. Even if the physician does not duplicate the key components that the nonphysician practitioner (NPP) performed, you can count all medically necessary history, examination, and medical decision making that the and physician each individual performs and documents on a calendar day.

10. Apply your new/established patient rules when coding visits that would have been consults under Medicare’s old rules. For example, say an internist sends a patient to a cardiologist for an opinion, and that patient saw that cardiologist two years before. The cardiology practice should choose from the ‘established’ patient codes to bill the visit.
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