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Government Policy

HIPAA Compliance in the Cloud

This short article in Forbes on-line summarizes concerns with compliance to — and related costs — updates in HIPAA (Health Insurance Portability and Accountability Act). As noted, security and privacy are getting more serious with each iteration.

This is no small concern:

The Department of Health and Human Services estimates that the cost of compliance with the final rule will be somewhere between $114 and $225 million (first year) and about $14 million for each year thereafter… the rule qualifies as an “economically significant” one under Executive Order 12866.

The reason for this new level of security is pretty fundamental. Healthcare has had some serious deficiencies through the years and it’s a prime target for identity theft. Not so much for the actual healthcare information but for financial fraud – which is a companion problem in healthcare (to the tune of about $70 billion a year in Medicare fraud alone).

Read more…

Hospital Billing Varies Wildly, Government Data Shows

As this New York Times article details, data being released for the first time by the government on Wednesday shows that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely.

The data for 3,300 hospitals, released by the federal Center for Medicare and Medicaid Services, shows wide variations not only regionally but among hospitals in the same area or city. For instance, in Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,000. A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945.

Hospitals submitted bills to Medicare that were, on average, about three to five times what the agency typically pays to treat a condition, an analysis of the data by The New York Times indicates. And variations between what hospitals charge may be even greater.

The data covers bills submitted from virtually every hospital in the country in 2011 for the 100 most common treatments and procedures performed in hospitals. Medicare does not actually pay the amount a hospital charges but instead uses a system of standardized payments to reimburse hospitals for treating specific conditions.

Private insurers do not pay the full charge either, but negotiate payments with hospitals for specific treatments. Since many patients are covered by Medicare or have private insurance, they are not directly affected by what hospitals charge.

Experts say it is likely that the people who can afford it least — those with little or no insurance — are getting hit with extremely high hospitals bills that may bear little connection to the cost of treatment.

Read more…

A New Kind of Care for Adults

New York City may be facing a predicament as the prevalence and popularity of social adult day care centers is on the rise, especially in the Brooklyn area.

With the largest Medicaid budget in the country at $54 billion, the city is trying to find a way to balance spending for institutional care with less expensive care methods that allow people to remain in their communities.

These spending concerns arise as the number of social adult day care centers has grown from eight programs to 192 centers across the city.

Why has the number grown so much so quickly? The answer lies within their aggressive marketing tactics. To entice people, a facility may offer $50 for a referral, money each week, free food to take out, a grocery coupon, or an unlimited MetroCard.

Medicaid indirectly pays for the cost of attendance. Managed care companies pay the adult day care centers to provide services to its clients. In return, the centers refer new clients to these companies.

“Centers collected $25 million for managed care plans in the first nine months of 2012.” The rate per month for each member is about $3,800 or $93 per session. Read More…

Furthermore, these care centers are fairly inexpensive to operate because they are minimally regulated, do not require a license and only require a staff of two people, one of whom can be a volunteer.

Those who receive treatment are supposed to be impaired enough to need at least 120 days of help with everyday tasks. However, the The New York Times article,“Day Centers Sprout Up, Luring Fit Elders and Costing Medicaid,” reports that healthy individuals may be reaping the benefits of a superfluous Medicaid budget.

“The idea that people are bicycling home from managed long-term care is a complete misnomer…The idea that they’re playing Ping-Pong — I guess they could be wheelchair-bound Ping-Pong players, but otherwise it’s fraud and they are not eligible,” said Jason Helgerson, the state’s Medicaid Chief.

Obamacare & Medicare Advantage Update

As the future of Obamacare falls into place, many health insurers are pleased with recent outcomes.

The government recently made decisions regarding Medicare Advantage rates, the future of Medicaid, and the Patient Protection and Affordable Care Act. 

Instead of Medicare Advantage rate cuts, participating insurers will receive a 3.3 percent i crease in payment reimbursements, which is more than what some had hoped for.  In addition, the Department of Health and Human Services is now fully responsible for Medicaid expansion costs.

“Expansion would broaden the coverage umbrella to include patients below age 65 who have income that’s 133% above the federal poverty level.” Read more…

Although many are able to rest easy after the conclusion of this decision, there are still numerous decisions to be made concerning state health insurance laws. 

To read more about details of these new decisions click here.

Trends with Benefits: The Growth of Federal Disability Benefits in the U.S.

One of MCN’s favorite radio programs is “This American Life” from National Public Radio. The March 22, 2013 show, “Trends With Benefits,” was on the massive growth in federal disability benefits in the U.S. Much of this is no surprise to those of us who work in the sector. To quote their blurb:

“The number of Americans receiving federal disability payments has nearly doubled over the last 15 years. There are towns and counties around the nation where almost 1/4 of adults are on disability. Planet Money‘s Chana Joffe-Walt spent 6 months exploring the disability program, and emerges with a story of the U.S. economy quite different than the one we’ve been hearing.”

Well worth a listen. This American Life: Trends With Benefits

And additional information in available from the author on the web at:

http://apps.npr.org/unfit-for-work/

Should the head of the NRA be restricted from owning guns?

By Brian L. Grant MD
If a sign of mental illness is delusional thinking and being out of touch with reality, Wayne LaPierre may qualify. His ongoing rants suggesting that there exists some sort of mental health database that if consulted, would screen out murderers, is absurd.

Mr. LaPierre, please show us what you refer to. Also, please demonstrate how many — if any— of those thousands of killers who used firearms were in this non-existent database?

I hope you are not suggesting that an individual who seeks counseling or psychotherapy from a psychiatrist or psychologist, or antidepressants from their primary care doctor should be entered in a registry restricting their current firearm rights?

To do so would fly in the face of logic, privacy, and have zero impact on the problem of gun deaths. There is no linkage between seeking mental health care and dangerousness, and any such registration would only serve to deter individuals from addressing issues that might then go untreated.

Any mental health professional possessing appropriate humility knows that their record of predicting dangerousness is little better than the general public.

The public depiction of some of the recent mass killers certainly describe strange individuals, who before their act are not unlike those that one might find in large numbers in any high school class, software, Star Trek, or dare I say, Psychiatry convention. Hindsight bias, where something suddenly becomes obvious after the fact, is simple but misguided.

The proximate cause of gun deaths are guns and bullets. Killers armed with less lethality may be less dangerous toward others and themselves.

Do we collectively as a society have the political will and common sense to at least confine our arguments to reality?

Read More at:  The Economist: “Why the NRA keeps Talking about Mental Illness, Rather than Guns.”

An Overview of a Sick Health Care System

By Brian L. Grant, MD

This very detailed, long, and comprehensive report from Time  states the obvious to many who have paid attention to the debacle of our health care system.

It is long, but the best summary I have seen making the case for a need to revamp and disrupt the U.S. health care system. The article, “Bitter Pill: Why Medical Bills Are Killing Us,” details how:

“In the U.S., people spend almost 20% of the gross domestic product on health care, compared with about half that in most developed countries. Yet in every measurable way, the results our health care system produces are no better and often worse than the outcomes in those countries.”

A response to the article in Slate criticizes the article on giving doctors and their pay a pass.

Obviously this hits close to home for this writer and many readers of MCNTalk. It actually hits home for every American.

It will enlighten and disturb most. Readers may even learn a new word: Chargemaster. Learn what this means and why it is important to you.

What is clear is that virtually every interest group invested in health care stands to lose a lot if the system truly rationalizes itself structurally and functionally in a way that addresses the major dysfunctions in the current U.S. system.

If the 18+ GDP being currently spent in the U.S. were to decrease to a level consistent with other industrialized countries, that means the spend will be less and the income of impacted stakeholders in our present system may decrease.

This article ought to make readers angry and concerned, enough to do their own analyses rather than accept the rhetoric designed to polarize. Simply put, our health care system is indefensively abusive to society.

Any system that charges those who can least afford to pay, the uninsured, many times that charged to Medicare patients and double that paid by private insurers, is wrong.

Any system that costs us as a society one out of five dollars – twice what other countries with systems equal in quality to ours – when it comes to major measures of health is wrong. Any system that abuses its nonprofit status, holds charity balls to cover the 1% or so that it may give away, while ending up with 12% or more of untaxed profits, paying its key executives in the many millions each – is wrong!

The article says little about the unnecessary nature of much of the care received by patients and the excesses in care with respect to labs, medications, therapies and other interventions. There are no health care bills when one does not receive care that is not needed or when one is healthy in the first place. And preventative care should be evidence based, not automatic.

This writer is in the medical business, as a physician, patient, employer, and in a role with a business that every day analyzes and reviews care received or proposed. I know a train wreck in process when I see it.

The political divisiveness and partisanship that surrounds the health care debacle is not accidental. It is carefully calculated and brilliantly executed by political operatives on behalf of those who stand to lose.

How fascinating that many of those who suffer the most in the current system, most revile the president and party who have proposed solutions that might mean a few less folks would need to declare bankruptcy from their medical bills.

At some point in the relatively near future, change will be forced by political will and those who have been tricked into opposing change will see the errors of their ways. Those businesses who are footing ever increasing bills for private insurance will also decide that they are fed up.

Changes will be fought hard, with desperate claims to maintain the status quo. It is in the interest of those most impacted to be part of solution rather than have it be imposed on them.

In the interim, pray that you, your friends, and loved ones never show up at a hospital with none or inadequate insurance. And welcome the day you are eligible for Medicare.

We invite readers’ responses to this article. We would especially like to hear counterpoints to the main points raised in the article.

 

Should California Workers’ Comp Cover Pro Athletes from Any Team?

Workers’ Compensation has a clear place in society.

Professional athletes, especially football players, often sustain chronic injuries from their play.

The Los Angeles Times article, “Athletes Cash In On California Workers’ Comp,” addresses how many California workers’ compensation judges have held that any professional athlete who plays in the state is eligible to receive benefits from employers.

“Over the last three decades, California’s workers’ compensation system has awarded millions of dollars in benefits for job-related injuries to thousands of professional athletes. The vast majority worked for out-of-state teams; some played as little as one game in the Golden State.

All states allow professional athletes to claim workers’ compensation payments for specific job-related injuries — such as a busted knee, torn tendon or ruptured spinal disc — that happened within their borders. But California is one of the few that provides additional payments for the cumulative effect of injuries that occur over years of playing.” Read More…

California’s particular workers’ compensation regulations appear to have created coverage for players from any team that played in California during their career. Is this good policy?

Are Your Health Benefits Cutting Your Pay?

This thoughtful and depressing article from the New York Times describes the actual health care costs to individuals in graphic terms; how it impacts their salary and how the political process ensures that the high costs continue.

The author closes with a modest proposal on how the system might change by only insuring for unexpected, catastrophic illness – leaving the remainder to individuals to self-insure.

Clearly such a suggestion would be resisted by most everyone. We currently consume health care in the context that we expect routine and affordable treatments such as teeth cleaning, eyeglasses, and contraception be paid for by someone else.

Most of us will drive a mile to save a couple of  cents on gas. If our car insurance paid for gas,  which it would if health insurance behavior applied to cars, not only would we go to the closest station, but the price of the gas would not be posted. Read More…

Will Self-Insurance Plans Drive Up Costs for Others?

A New York Times article addresses the self-insurance trend as some companies with relatively young and healthy employees decide to opt out of the health insurance marketplace.

Though it is unclear whether employers  are deciding to self-insure as a response to the Affordable Care Act, companies have found they can avoid the laws’ minimum coverage standards and save money by doing so.

“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”

However, this change could drive up costs for employees at other companies because commercial insurers and insurance exchanges will be left with disproportionate numbers of older and sicker people who are more expensive to insure. This could drive up premiums for uninsured people seeking coverage in the exchanges and since the federal government subsidizes that coverage, it could face higher costs as well.