Urgent Care by Minda Wilson

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Friday, 23 June 2017

The Senate Draft Plan is out and it is hard to believe

Affordability is Not Part of New Senate Plan

The Senate Draft Plan is out and it is hard to believe that it, again, failed to create some kind of solution to the ongoing issue, affordability of healthcare. Key components include greater latitudes for states to opt out, the rollback of taxes, phase down of Medicaid expenses, and having subsidies based on income vs. age, but reducing these subsidies over time.

Phasing down of Medicaid means one thing, reduction in benefits. It means a narrower network with fewer doctors and longer waiting lists and less access.

Rolling back of taxes means less money. Less money means a bigger deficit. As long as the government continues to subsidize healthcare the deficit will continue to grow. One way they could save significant money would be to dismantle the exchanges, but it is not clear that that is the intention.

Subsidies based on income and not age makes tremendous sense.

Why would a person like Mark Cuban,

who is under 65, need a subsidy?

The people who need the money and need the care is where we should put in our safety net.

It is surprising to consider, though, that in certain circumstances, the self-employed and/or those who must purchase individual policies may be better off without insurance. The cost of a family policy is about $20,000+ dollars for 2018. For those not eligible for subsidies, for example, someone making about $100,000, this is a significant expense. In addition, the deductible for such a policy is about $2,500 per person; or about $10,000 for a family of 4. Given this, you are looking at out of pocket expenses of about $30,000 after tax. Which means that, after paying taxes, of every dollar that is left, 35 cents will be going out for healthcare before the family has eaten, paid rent, bought clothes, paid for transportation, etc. This is not workable. It is unlikely that such a family will spend $30,000 on health care in any one year. If they could save that money, or a significant portion of it to cover future catastrophic events, the family would be significantly better off.

As people on subsidies see their subsidized portion decrease, they will be in the same boat as the high earners who self-insure; except they will be earning less.

In reality, the fact that insurance costs $20,000 per family is where the problem is. And, the fact that of that $20,000 so little, across the board, is actually spent on care, makes it more of a problem. According to a study by the CDC, of all 18 to 64-year-olds, after subtracting the deductible from healthcare costs paid, insurance companies pay out less than 10% of the money they take in to cover the cost of care.

The solution is limiting administrative costs. Cutting senior level compensation in the three largest insurance companies would allow significant reductions in policy costs. So, if you look at it that way, if administrative costs were cut in half; a $9,000 savings could be achieved for next year and your policy, instead of costing $20,000, would cost $11,000.

Its our money the politicians are using to pay for these policies.

Why couldn’t the politicians figure this out?

Minda Wilson

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Tuesday, 30 May 2017

Involved in automobile accident you pay upfront first

Involved in automobile accident you pay upfront before your medical insurance does well if the courts agree that is...

Could This Really Be True?

Sarah (her name has been changed) got an EOB, explanation of benefits, saying that Blue Shield of California denied coverage for appointments related to her back injury because the doctor’s notes mentioned that the back injury was a result of a car accident.

Picture this: You are a passenger in a car driven by your friend. A drunk driver plows into you and you are seriously injured. You are taken from the accident site to the ER; treated for a concussion and injuries to your back and neck. It is clear you will need additional and ongoing treatment. You are referred to a neurologist for the head injury, an orthopedist for the back and neck injury, and a physical therapist.

In the old days, if you were the passenger, your insurance would pay for your medical bills, even though the insurance of the person that hit you would ultimately be responsible for paying those bills. Your insurance company would become a party to the lawsuit against the driver responsible and would attempt to recover monies advanced. If the person who hit you was found to be at fault, the insurance company would recover what they advanced. If the court ruled against them, they would recover nothing. Either way, Sarah would not be responsible for coming up with the money for paying bills that would otherwise be covered by her insurance.

The Blue Shield representative explained to Sarah that, in the case of an automobile accident, Blue Shield is no longer willing to put up the money in advance of a settlement. What this means is Sarah is the financially responsible party to the hospital, the doctors, the physical therapist, and any other party that provided medical treatment related to the accident. It also turns out, that since the insurance company is not responsible for these bills until the court says they are, the out of pocket payments you make are not counted towards your deductible.

The question is “Why?”

Blue Shield believes that they are in second position to the drunk driver’s insurance. Blue Shield is only responsible for paying what the primary insured does not pay. Both these statements are true. Based on these beliefs, Blue Shield has decided that they should no longer advance money to those who are injured in automobile accidents unless and until it is clear that Blue Shield is the party responsible for those payments. When they pay and it turns out they are not responsible Blue Shield risks that they won’t be able to recoup their payments.

Seems like a wise business decision.

This seems like just another step in the process to transfer financial risk for one’s healthcare away from insurance companies.

According to the Kaiser foundation, annual premiums for employer-sponsored family health coverage reached $17,545 in 2015, with workers on average paying $4,955 towards the cost of their coverage; individual policies cost more. Since 2015 these costs, have increased, on average, greater than 25%. This means that a company with 50 or more employees is likely to spend over a million dollars annually on health insurance. As a result of risk transfer, more of the costs for healthcare are being born by the employee. In addition to the $5,000 they pay for the premium, individual deductibles are averaging $2500 and family deductibles are $10,000. In California, the all in cost for a policy including deductibles and co-pays exceeds $30,000, if you don’t receive a subsidy. These increases are not economically sustainable.

In any other business, when one abuses one’s customers, they go elsewhere. New reform proposals focus on giving more power to insurance companies. Inter-state operations allows insurance companies to build operations in multiple states, but more overhead is required to manage a larger operation. In addition, except for federal benefits, regulations on policies in each state must still be met. There is no guarantee that cost savings will result. Tax breaks and subsidies may help ease the pain, but they to nothing to curb price increased that are expected to be passed onto the consumer.

There could be some price relief from disruptive product offerings coming from outside the insurance industry. Otherwise, the will continue to experience the abusive cycle of risk transfer, price increases, and declining benefits.

Minda Wilson

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Friday, 31 March 2017

The Problem Isn’t Obamacare…It’s The Insurance Companies

Primary Care Doctor Explains:

“The Problem Isn’t Obamacare…It’s The Insurance Companies”

With premiums increasing for those with coverage through the ACA marketplace, a lot of people are criticizing Obamacare. But many doctors and healthcare professionals are saying that isn’t really the problem.

Cathleen London is a primary care physician in Milbridge, a rural town in Maine. She claims the problem isn’t Obamacare itself, but rather, the entire health insurance system and insurance companies are to blame.

Writing for the Portland Press Herald, London explains she is a a primary care physician who is on the front lines every single day, as her town is very remote, which means it takes 30 to 40 minutes to get to the emergency room, which is why her office operates as an urgent care facility as well as a family medical practice.

It’s takes an ambulance about 20 minutes to get to her clinic and specialist care about 2 hours away, so Dr. London is trained to handle about 90 percent of medical problems.

DR. LONDON EXPLAINS THE FOLLOWING, WHICH WILL SHOW YOU EXACTLY WHAT’S WRING WITH HEALTH CARE:
One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.

Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.

I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.

I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.

The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).

Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.

Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.

I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.

I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.

My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.

Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.

This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies.

Remember lifetime caps?

Remember denials for pre-existing conditions?

Remember the retroactive cancellation of insurance policies?

Returning to that is not an option.

Indeed it is not an option, Dr. London. If Republicans get their way eventually by repealing Obamacare, it may be where we end up again. If Republicans really get their way, it’ll be even worse than it was before.

Minda Wilson

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Thursday, 16 March 2017

Jordyn 21 Year Old Boy Killed by His Insurance Company

This is a true story.

Due to the fact that their son's death is so recent and raw, I have changed some of the details so protect the family.

"The story you are about to read is true, the names were changed to protect the innocent."

On the morning of Sunday, March 5th, at 4 am, Jordyn Smith died. Jordyn was 21 years old. While he didn't know exactly what he wanted to do with his life, he was working on it. He was handsome, over 6 feet tall, strapping, and athletic. He had a close group of friends that he had known since kindergarten. Each one spoke at his funeral and told a story about how special he was to them and how much they meant to each other.

Jordyn liked to go to parties and, admittedly, had a drink or two with his friends before he turned 21. The thing is, he never smoked. He was passionate about music, loved rap. He loved his sports teams and rooted passionately for the Rams. You could never say a bad thing about them. He was a typical boy from a relatively small suburb growing up and finding his way.

Eighteen months ago, he was diagnosed with lung cancer. For over a year, he was in and out of the hospital. First chemotherapy, then surgery. They removed a good section of his lung. This made him so sad because he was worried about whether he would have the wind to keep up with his friends when he was well. Everyone told him that, once he got done with his treatments, and started exercising, his lungs would expand and he would be able to play soccer and basketball, two things he loved.

After the surgery, he had a lot of pain, which never really got better. Worse, more treatments followed. He had more radiation, more chemo. His skin hurt from the radiation. Through it all he was stoic and silent; complaining little and keeping up a strong front for his family.

After New Year, it looked like we were out of the woods. Several months had passed since his last treatment. There was talk of another round of chemo, but his tests were clear and he was recovering. He felt so good that there was a big celebration party at his house and he started going to football games to see his beloved team. And then it happened . . . .

Jordyn got a cold; a cold! Because of the vulnerability of his lungs, it turned into pneumonia. He couldn't breathe. Within a week of getting sick, he was back in the hospital, hooked up to a breathing machine. It took several weeks to get him off the machine and to stabilize him. This last Friday, it looked liked he was finally going to be transferred out of the hospital to a rehabilitation facility. The hospital required to test for infection prior to transfer. When the blood tests came back, he had tested positive for infection. Thirty-six hours later he was dead.

How could Jordyn have gone from able to be discharged to full blown pneumonia,

without it being detected?

Jordyn was another victim of the Affordable Care Act, and the power it imbued our insurance companies. Insurance companies, not doctors, now dictate how often blood can be "routinely" tested or chest x-rays taken for a patient like Jordyn in order for a hospital to be reimbursed.

If more frequent testing is recommended by the doctor, to get paid approval is required. If no approval is forthcoming, who gets stuck with the bill? The delay, deny, die mantra of insurance companies let you know right away how long it will take to get and answer and the law gives them up to 90 days to respond. For Jordyn, it led to his death.

Minda Wilson

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Tuesday, 7 March 2017

Minda WIlsons Response to Republican Proposals

President Trump said that healthcare is complicated. It is complicated;

but fixing healthcare is not.

The solution is simple and comes in 3 parts:

1) True health insurance coverage, by a licensed entity, ie insurance company, gifting program, MEWA, or other legally approved entity, will provide catastrophic coverage, only. This means that preventative care will not be covered. Those costs should be paid individually by money set aside in your Health Savings Account, see below.

2) In the aggregate, the price an insurance company charges for its policies should be no more than 1.4 times the money paid out by that insurance company for medical related services.

3) All Americans should be able to set up Health Savings Accounts for themselves and their family members. Contributions can be made by both employers, employees, and individuals. Caps for these accounts should be set no lower than the cost of a family deductible, today about $10,000.

This proposal ties policy prices to money actually paid out for care. If they spend more on care for your fellow policy holders your policy price will go up. If they spend less, your policy price will go down. The money they get for administration will be directly tied to the cost of care. They less they spend on care the less they receive for administration. It is just that simple. You will be responsible for your individual healthcare needs. If you don't take care of yourself, you will pay more.

Fixing healthcare only becomes complicated when you stop thinking about what a viable solution would look like and start thinking about how you can satisfy the insurance companies needs to continue using funds that are supposed to be used to pay for customer's healthcare needs, but instead are used to pay for health insurance company expenses.

The legislative proposals call for more health "insurance". Allowing insurance companies accesses to more insureds and relying on them to agree to reduce costs makes no sense. As a business person, if someone said, "I'll send more customers your way and let you decide whether or not your think the extra business is enough to make you consider lowering your prices!" , the odds of me lowering those prices is slim and none.

Affordability seems to be off the table. Policy costs will continue to be negotiated at the state level. Since all insurance companies typically have to do to raise rates is show more losses than anticipated or more expenses than anticipated, the odds of rates going down any time soon are non-existent. Interstate insurance will allow companies incorporated in the most advantageous states to out compete those who are incorporated in states with higher levels of consumer protections. While tax subsidies and/or tax credits are being considered, lower income families, and families that do not file itemized returns will receive little or no benefits.

Americans seem to have confused health insurance with health care. Health insurance is supposed to spread the risk so that everyone who participates pays a little so that no one person has to pay a lot if they get sick. Health insurance companies have become an investment vehicle to enrich senior executives. As long as we continue to allow them to spend only 10% of what comes in to pay for the actual care part of their policy holders , there won't be much care there.

"The answer to our problem is to hold our insurers accountable; not promise them more business with no consideration for how much we will be charged"

Minda Wilson

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CNN Healthcare Debate with Jake Tapper & Dana Bash

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Friday, 10 February 2017

Debate Night - Future of Obamacare, Cruz vs. Sanders

Future of Obamacare, Cruz vs. Sanders

Minda Wilson , Author of Urgent Care response on the CNN debate

"If the debate taught us one thing, we learned that both participants come from very different philosophical points of view, are very passionate about what they believe and don't let the facts get in the way of their positions.

In the hair splitting department, Bernie Sanders believes that healthcare is a right, while Ted Cruz believes healthcare access is the right of all Americans.

Because healthcare is a right, Sanders expects the government to absorb the cost of providing it, no matter how great the financial burden would be. While Sanders expects the top 1% of the country to pay for it, he sees himself as a part of that group. If His income as a Congressman puts him in the top 1% of earners. If he doesn't have the money, who does? According to Senator Cruz, if we confiscated all the wealth from the "wealthy" we would not have enough revenue to carry for one year the additional costs of a single payer system which would provide healthcare to all Americans.

According to Ted Cruz, "What we should care about is access to healthcare, not insurance per se. " This means that all people should have access to healthcare, but they still should pay for it themselves. With insurance costing at least $10,000 for a family and deductibles in excess of $5,000, how is the average family going to pay for their care? Cruz thinks that allowing insurance companies to compete across state lines and reducing regulations the insurance companies because they would be making more money, would, out of the goodness of their hearts, pass this increased revenue onto consumers by reducing their prices. This would result in a reduced costs for the family.

Both parties acknowledged our obligation to assist those who need help. Agreement at last. They also agreed that it is insurance companies and drug companies that are the bad actors in the story of escalating healthcare costs. Both acknowledged that drug companies are not required to negotiate prices. It was Ted Cruz who reminded us that, since the passage of Obamacare, health insurance profits have doubled and their margins have dramatically increased. This means that the margins on each policy sold were greater than before Obamacare was passed. However, when it came to tackling the problem of rising costs, both looked to the uncontrolled insurance companies to provide us with a solution. Neither proposed any controls on costs.

Gruber, in his post-debate interview said, the problem with Obamacare was that insurance companies were not given the protections they wanted in order to participate in that market. Both Senators Cruz and Sanders would think this is ridiculous. Bernie thought insurance company executives were making enough money and didn't need more. It was Cruz and his Republicans that voted against releasing an addition $7plus billion dollars to insurance companies to cover losses on Obamacare policies when those same companies were experiencing record profits.

What they didn't talk about was how the position each was advocating for had already failed. In Congressman Sanders own state of Vermont, a single payor system was tried. The system worked so badly and ended up costing so much that less than a year after it was enacted, Vermont pulled the plug. They said that based on their one year of experience, state income taxes would have to be raised 10% across the board, for all taxpayers, in order to cover the costs of their single payor plan. A 10% increase in taxes didn't seem to make sense, especially since that would only cover the costs for subsequent years if there were no increases. Cruz's plan, establishing high-risk pools, has also been tried. Since the aids crisis, high-risk pools have been available to allow people with pre-existing conditions to obtain coverage. The problem was that these programs were not free, they still had to pay for their insurance and, people who were seriously ill couldn't afford the premiums, even though they were subsidized.

So, expanding markets, single payor, giving people more choice of carriers, all the proposals that were made are still insurance based products run by insurance companies. If affordability is the key, the only way that is going to happen is to rein in insurance costs. This will only happen if we regulate the percentage administrative costs allowed by subtracting from the premium dollars received the money paid for medical expenses and services rendered (money in minus money out).

What came out of this is proof that neither Ted Cruz nor Bernie Sanders are familiar with the laws they have already passed. A woman asked the question about what would happen to pregnancy and newborn coverage if Obamacare was repealed? Sanders said she would be uncovered if Obamacare was repealed. Cruz was simply silent. The answer is that women and children already are covered if they are unable to obtain coverage because they can't afford it. We already had legislation on the books. In 1997, Edward Kennedy and Orin Hatch, the odd couple of healthcare, worked together to pass the Children's Health Insurance Program, administered by the United States Department of Health and Human Services. For families with incomes that are modest but too high to qualify for Medicaid, the CHIPs program provides coverage for pregnant women who do not already have pregnancy coverage as well as coverage for uninsured children in families. For those whose qualify for Medicaid, pregnancy is automatically covered, as is coverage for any children born of Medicaid recipients.The reason that proposing a solution is so hard is that emotion, philosophical bias, and lack of familiarity with the facts keeps getting in the way."

Minda Wilson
Author of Urgent Care

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