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AMA's Heal that Claim Month

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AMA's Heal that Claim Month

AMA wants physicians to stake a claim for accurate insurer payments this fall

AMA
October 29, 2008

As part of its national campaign to save the health system billions of dollars by improving the accuracy and efficiency of medical claims processing, the American Medical Association (AMA) today announced it has selected November for the first national Heal that Claim Month.

Many physician practices often experience an increase in claim denials from health insurers during the last quarter of the year, making November an ideal time to appeal inappropriately underpaid and denied claims. An estimated 90 percent of claim denials are preventable and 67 percent of denials are recoverable, according to the Advisory Board Company, a Washington-based research organization. Based on those estimates, physicians collectively lose billions of dollars a year of revenue to health insurers.

Heal that Claim Month is part of the AMA’s ongoing Heal the Claims Process campaign, which launched last June with the unveiling of the AMA’s first National Health Insurer Report Card, an objective comparison of the nation’s largest health insurers and their claims processing performance.

http://www.ama-assn.org/ama/pub/category/20209.html

And…

2008 National Health Insurer Report Card

AMA

Contracted payment rate adherence

On what percentage of records does the payer’s allowed amount equal the contracted payment rate?

Aetna – 70.78%
Anthem – 72.14%
CIGNA – 66.23%
Coventry – 86.74%
Health Net – not reported
Humana – 84.20%
UHC – 61.55%
Medicare – 98.12%

http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf

And…

Appeal that Claim

AMA

When a physician practice assumes that the reimbursement it receives from health insurers is always accurate, the practice may lose revenue. Even when a practice codes claims correctly, health insurers may still inappropriately deny, delay or significantly reduce payments. By implementing claims auditing processes, you can ensure that health insurers pay your practice appropriately for your physician procedures and services.

Step 1: Determine who will be responsible for auditing health insurer payments

Step 2: Collect recommended health insurer auditing resources

Step 3: Run monthly collection reports

Step 4: Review the health insurer explanation of benefits (EOB)/remittance advice (RA) on each claim identified on the collection report

Step 5: Identify the health insurer basis for the denied, delayed or partially paid claim

Step 6: Gather supporting documentation to corroborate reversal of the health insurer’s determination through the claims appeals process

Step 7: Develop a claim appeal letter and resubmit the claim to the health insurer

Step 8: Maintain a health insurer follow-up log

Step 9: Hold claims processing and review meetings

Step 10: Continue to appeal inappropriately denied, delayed or partially paid claims

Appeal that Claim (65 pages):
http://www.ama-assn.org/ama1/pub/upload/mm/368/appeal-that-claim.pdf

Comment:

By Don McCanne, MD

The AMA has selected November as the first national Heal that Claim Month. The problems that this addresses must be fairly significant if they are going to declare a special month to address them; so what are these problems?

The U.S. health care financing system is infamous for its profound administrative waste. Some of it is due to the fragmented system of a great multitude of private payers plus public programs with various rules and regulations which increase the complexity of the billing process. Besides the administrative costs of the insurers, which is typically about 18 percent of their premiums (i.e., medical loss ratio of 82 percent), the administrative burden that this system places on physicians and hospitals consumes about another 12 percent of the insurance premiums.

These numbers refer to the routine of claims preparation and processing. But the 2008 National Health Insurer Report Card demonstrates that the nefarious behavior of the private insurers has compounded the complexity by reimbursing at rates significantly below those that were established in contracts with the physicians.

The private insurers are cheating, and they depend on physicians being overwhelmed by this administrative burden to not get caught in their evil deeds. This goes far beyond the complex routine of private insurance administrative processes. This is racketeering.

In the ultimate of ironies, the AMA has responded with an additional, complex, burdensome administrative process to ferret out the private insurers that cheat (which is all of them!), so that they can demand reimbursement at rates that the insurers contractually agreed to. Understanding the element that they are dealing with, the final step recommended is to continue to assert compliance with these contracts agreed to by these recalcitrant crooks.

So what is the AMA recommendation for reforming this horrendous, highly wasteful system? More of it! They want to expand the market of private health plans and use our tax funds to provide credits for purchasing these plans.

The AMA should take a closer look at their own National Health Insurer Report Card. All of the private insurers are crooks, but our own public insurer, Medicare, has over a 98 percent compliance with contracted rates. Just imagine if Medicare were the only payer. The ease and transparency of the process would likely result in 99.99 percent compliance.

Instead of wasting more time and resources on a Heal that Claim Month, we need to proclaim January 2009 as a New and Improved Medicare for All Month!

AMA’s Heal that Claim Month

AMA wants physicians to stake a claim for accurate insurer payments this fall

AMA
October 29, 2008

As part of its national campaign to save the health system billions of dollars by improving the accuracy and efficiency of medical claims processing, the American Medical Association (AMA) today announced it has selected November for the first national Heal that Claim Month.

Many physician practices often experience an increase in claim denials from health insurers during the last quarter of the year, making November an ideal time to appeal inappropriately underpaid and denied claims. An estimated 90 percent of claim denials are preventable and 67 percent of denials are recoverable, according to the Advisory Board Company, a Washington-based research organization. Based on those estimates, physicians collectively lose billions of dollars a year of revenue to health insurers.

Heal that Claim Month is part of the AMA’s ongoing Heal the Claims Process campaign, which launched last June with the unveiling of the AMA’s first National Health Insurer Report Card, an objective comparison of the nation’s largest health insurers and their claims processing performance.

http://www.ama-assn.org/ama/pub/category/20209.html

And…

2008 National Health Insurer Report Card

AMA

Contracted payment rate adherence

On what percentage of records does the payer’s allowed amount equal the contracted payment rate?

Aetna – 70.78%
Anthem – 72.14%
CIGNA – 66.23%
Coventry – 86.74%
Health Net – not reported
Humana – 84.20%
UHC – 61.55%
Medicare – 98.12%

http://www.ama-assn.org/ama1/pub/upload/mm/368/reportcard.pdf

And…

Appeal that Claim

AMA

When a physician practice assumes that the reimbursement it receives from health insurers is always accurate, the practice may lose revenue. Even when a practice codes claims correctly, health insurers may still inappropriately deny, delay or significantly reduce payments. By implementing claims auditing processes, you can ensure that health insurers pay your practice appropriately for your physician procedures and services.

Step 1: Determine who will be responsible for auditing health insurer payments

Step 2: Collect recommended health insurer auditing resources

Step 3: Run monthly collection reports

Step 4: Review the health insurer explanation of benefits (EOB)/remittance advice (RA) on each claim identified on the collection report

Step 5: Identify the health insurer basis for the denied, delayed or partially paid claim

Step 6: Gather supporting documentation to corroborate reversal of the health insurer’s determination through the claims appeals process

Step 7: Develop a claim appeal letter and resubmit the claim to the health insurer

Step 8: Maintain a health insurer follow-up log

Step 9: Hold claims processing and review meetings

Step 10: Continue to appeal inappropriately denied, delayed or partially paid claims

Appeal that Claim (65 pages):
http://www.ama-assn.org/ama1/pub/upload/mm/368/appeal-that-claim.pdf

Comment:

By Don McCanne, MD

The AMA has selected November as the first national Heal that Claim Month. The problems that this addresses must be fairly significant if they are going to declare a special month to address them; so what are these problems?

The U.S. health care financing system is infamous for its profound administrative waste. Some of it is due to the fragmented system of a great multitude of private payers plus public programs with various rules and regulations which increase the complexity of the billing process. Besides the administrative costs of the insurers, which is typically about 18 percent of their premiums (i.e., medical loss ratio of 82 percent), the administrative burden that this system places on physicians and hospitals consumes about another 12 percent of the insurance premiums.

These numbers refer to the routine of claims preparation and processing. But the 2008 National Health Insurer Report Card demonstrates that the nefarious behavior of the private insurers has compounded the complexity by reimbursing at rates significantly below those that were established in contracts with the physicians.

The private insurers are cheating, and they depend on physicians being overwhelmed by this administrative burden to not get caught in their evil deeds. This goes far beyond the complex routine of private insurance administrative processes. This is racketeering.

In the ultimate of ironies, the AMA has responded with an additional, complex, burdensome administrative process to ferret out the private insurers that cheat (which is all of them!), so that they can demand reimbursement at rates that the insurers contractually agreed to. Understanding the element that they are dealing with, the final step recommended is to continue to assert compliance with these contracts agreed to by these recalcitrant crooks.

So what is the AMA recommendation for reforming this horrendous, highly wasteful system? More of it! They want to expand the market of private health plans and use our tax funds to provide credits for purchasing these plans.

The AMA should take a closer look at their own National Health Insurer Report Card. All of the private insurers are crooks, but our own public insurer, Medicare, has over a 98 percent compliance with contracted rates. Just imagine if Medicare were the only payer. The ease and transparency of the process would likely result in 99.99 percent compliance.

Instead of wasting more time and resources on a Heal that Claim Month, we need to proclaim January 2009 as a New and Improved Medicare for All Month!

Yes we can

November 4, 2008
Chicago, Illinois

President-elect Barack Obama:
America, we have come so far. We have seen so much. But there’s so much more to do. So tonight let us ask ourselves, if our children should live to see the next century, if my daughters should be so lucky to live as long as Ann Nixon Cooper, what change will they see? What progress will we have made?
This is our chance to answer that call. This is our moment. This is our time: to put our people back to work and open doors of opportunity for our kids; to restore prosperity and promote the cause of peace; to reclaim the American dream and reaffirm that fundamental truth that out of many, we are one; that while we breathe, we hope; and where we are met with cynicism and doubt and those who tell us we can’t, we will respond with that timeless creed that sums up the spirit of a people:
Yes, we can.
http://elections.nytimes.com/2008/results/president/speeches/obama-victory-speech.html

Yes we can!

Yes we can

November 4, 2008
Chicago, Illinois

President-elect Barack Obama:

America, we have come so far. We have seen so much. But there’s so much more to do. So tonight let us ask ourselves, if our children should live to see the next century, if my daughters should be so lucky to live as long as Ann Nixon Cooper, what change will they see? What progress will we have made?

This is our chance to answer that call. This is our moment. This is our time: to put our people back to work and open doors of opportunity for our kids; to restore prosperity and promote the cause of peace; to reclaim the American dream and reaffirm that fundamental truth that out of many, we are one; that while we breathe, we hope; and where we are met with cynicism and doubt and those who tell us we can’t, we will respond with that timeless creed that sums up the spirit of a people:

Yes, we can.

http://elections.nytimes.com/2008/results/president/speeches/obama-victory-speech.html

Comment:

By Don McCanne, MD

Yes we can!

Single Payer Ballot Question Passes by Landslide in 10 Districts

Dear Single Payer Supporters

In an election that has brought out the highest voter turnout in Massachusetts probably since 1928, local ballot initiatives supporting single payer and opposing individual mandates passed by landslide margins in all ten legislative districts where they appeared. With almost all precincts tallied, roughly 73 percent of 181,000 voters in the ten districts voted YES to the following:

“Should the representative from this district be instructed to support legislation creating a cost-effective single payer health insurance system that is available to all residents, and oppose laws penalizing those who fail to obtain health insurance?”

The measure passed with margins ranging from 65 percent in the Fifth Middlesex to 82 percent in the Third Hampshire. Below is a table of results, which you can also see – along with other local non-binding referendum outcomes – at the Boston Globe website:

http://www.boston.com/news/politics/2008/election_results/ma_localquestions/

District No Yes Yes % Total
First Hampshire District 4,085 16,395 80.05% 20,480
Third Hampshire District 2,571 11,437 81.65% 14,008
Second Franklin District 4,162 12,471 74.98% 16,633
Fifth Middlesex District 6,263 11,896 65.51% 18,159
Twelfth Middlesex District 4,384 11,556 72.50% 15,940
First Barnstable 4,575 9,366 67.18% 13,941
Fourth Barnstable 6,897 17,262 71.45% 24,159
Barnstable, Dukes & Nantucket 5,953 15,951 72.82% 21,904
Tenth Suffolk 5,221 10,757 67.32% 15,978
Fourth Plymouth 5,312 15,381 74.33% 20,693
Total 49,423 132,472 72.83% 181,895

We will soon have a page up on Mass-Care’s web-site with the final results, along with a history of single payer ballot questions in Massachusetts.

Thanks to everyone in these ten districts for your hard work, and congratulations!

Mass-Care: The Massachusetts Campaign for Single Payer Health Care
33 Harrison Ave – 5th floor
Boston, MA 02111
Ph: 617-723-7001
Fx: 617-723-7002
Em: info@masscare.org

Doctors, citing mandate for change, call on Obama, Congress to 'do the right thing' on health reform

15,000 physicians urge enactment of single-payer system

FOR IMMEDIATE RELEASE
Nov. 5, 2008

Contact:
Quentin Young, M.D., (312) 782-6006, info@pnhp.org
Don McCanne, M.D., don@mccanne.org
David Himmelstein, M.D.
Mark Almberg, (312) 782-6006, cell: (312) 622-0996, mark@pnhp.org

A group of over 15,000 U.S. physicians has called on President-elect Barack Obama and the new Congress to “do the right thing” and enact a single-payer national health insurance plan, a system of public health care financing frequently characterized as “an improved Medicare for all.”

“Our country is hailing the remarkable and historic victory of Barack Obama and the mandate for change the electorate has awarded him,” said Dr. Quentin Young, national coordinator of Physicians for a National Health Program.

“In large measure Sen. Obama’s victory and the victories of his allies in the House and Senate were propelled by mounting public worries about health care,” he said. “Yet the prescription offered during the campaign by the president-elect and most Democratic policy makers – a hybrid of private health insurance plans and government subsidies – will not resolve the problems of our dangerously dysfunctional system.

“We’ve seen such hybrids repeatedly fail in state-based experiments over the past 20 years in Oregon, Minnesota, Washington and several other states, including Massachusetts, whose second go-round at incremental reform is already faltering,” Young said.

“The only effective cure for our health care woes is to establish a single, publicly financed system, one that removes the inefficient, wasteful, for-profit private health insurance industry from the picture,” he said. “Single payer has a proven track record of success – Medicare being just one example – and is the only medically and fiscally responsible course of action to take.”

“A solid majority of physicians endorse such an approach,” Young said. “An April 2008 study in the Annals of Internal Medicine shows 59 percent of U.S. physicians support national health insurance. Opinion polls show two-thirds of the public also supports such a remedy. Now, with strong political leadership, this reform is within reach.”

Young said the adoption of a single-payer health system can be a “major component of the new president’s economic rescue of Main Street.”

“We see no value in trying to bail out the private health insurance industry, an unsustainable system of financing care that has outlived its usefulness,” he said. “By contrast, a single-payer plan would provide direct and much-needed relief to millions of American households at a time of great economic hardship.”

“Only a single-payer system can achieve the goal of comprehensive and affordable care for all,” he said, noting that the estimated $350 billion administrative savings realized by replacing private insurers would be enough to cover all of the country’s uninsured and to end co-payments and deductibles for all Americans. “This would be the perfect way for President Obama to get the country back on track.”

“Patients would be able to go to the doctors and hospitals of their choice and not have to worry about being able to afford it,” he said, “and the single-payer system’s ability to do bulk purchasing, planning and global budgeting would rein in costs.”

Young noted that Obama has said more than once that he is a supporter of a single-payer universal health care program, and that if he were “starting from scratch,” he would favor adopting one. In 2003, Young said, then Illinois state Sen. Obama remarked that “first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”

Young remarked: “Tuesday’s election has made all of these conditions happen. In his first 100 days, President Obama has a window of opportunity to inspire the nation by championing the enactment of single-payer national health insurance under the slogan, ‘Everybody in, nobody out.’ Such a plan is embodied in the U.S. National Health Insurance Act, H.R. 676, introduced by Rep. John Conyers Jr. (D-Mich.) and co-sponsored by more than 90 others, more than any other health reform legislation.”

Young noted that at least five additional supporters of single-payer health reform were elected to Congress yesterday, including Senator-elect Tom Udall (D-N.M.), and that pro-single-payer ballot initiatives in 10 Massachusetts legislative districts “won by a landslide, on average receiving 73 percent of the vote.”

“Adopting a nationwide single-payer system will build on the great achievement of Medicare, further unify our people, strengthen our country’s economic competitiveness and assure President Obama’s legacy as an American hero,” Young said.

*****

Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, call (312) 782-6006 or visit www.pnhp.org/stateactions.

An analysis of Obama’s health care proposals by Dr. Don McCanne, senior health policy fellow at PNHP, can be found here.

A Kaiser Foundation interview with PNHP co-founder Dr. David Himmelstein about the elections and single-payer health reform can be found here.

The text of a recent “Open Letter to the Candidates on Single-Payer Health Reform,” signed by over 5,000 physicians, can be found here.

Doctors, citing mandate for change, call on Obama, Congress to ‘do the right thing’ on health reform

15,000 physicians urge enactment of single-payer system

FOR IMMEDIATE RELEASE
Nov. 5, 2008

Contact:
Quentin Young, M.D., (312) 782-6006, info@pnhp.org
Don McCanne, M.D., don@mccanne.org
David Himmelstein, M.D.
Mark Almberg, (312) 782-6006, cell: (312) 622-0996, mark@pnhp.org

A group of over 15,000 U.S. physicians has called on President-elect Barack Obama and the new Congress to “do the right thing” and enact a single-payer national health insurance plan, a system of public health care financing frequently characterized as “an improved Medicare for all.”

“Our country is hailing the remarkable and historic victory of Barack Obama and the mandate for change the electorate has awarded him,” said Dr. Quentin Young, national coordinator of Physicians for a National Health Program.

“In large measure Sen. Obama’s victory and the victories of his allies in the House and Senate were propelled by mounting public worries about health care,” he said. “Yet the prescription offered during the campaign by the president-elect and most Democratic policy makers – a hybrid of private health insurance plans and government subsidies – will not resolve the problems of our dangerously dysfunctional system.

“We’ve seen such hybrids repeatedly fail in state-based experiments over the past 20 years in Oregon, Minnesota, Washington and several other states, including Massachusetts, whose second go-round at incremental reform is already faltering,” Young said.

“The only effective cure for our health care woes is to establish a single, publicly financed system, one that removes the inefficient, wasteful, for-profit private health insurance industry from the picture,” he said. “Single payer has a proven track record of success – Medicare being just one example – and is the only medically and fiscally responsible course of action to take.”

“A solid majority of physicians endorse such an approach,” Young said. “An April 2008 study in the Annals of Internal Medicine shows 59 percent of U.S. physicians support national health insurance. Opinion polls show two-thirds of the public also supports such a remedy. Now, with strong political leadership, this reform is within reach.”

Young said the adoption of a single-payer health system can be a “major component of the new president’s economic rescue of Main Street.”

“We see no value in trying to bail out the private health insurance industry, an unsustainable system of financing care that has outlived its usefulness,” he said. “By contrast, a single-payer plan would provide direct and much-needed relief to millions of American households at a time of great economic hardship.”

“Only a single-payer system can achieve the goal of comprehensive and affordable care for all,” he said, noting that the estimated $350 billion administrative savings realized by replacing private insurers would be enough to cover all of the country’s uninsured and to end co-payments and deductibles for all Americans. “This would be the perfect way for President Obama to get the country back on track.”

“Patients would be able to go to the doctors and hospitals of their choice and not have to worry about being able to afford it,” he said, “and the single-payer system’s ability to do bulk purchasing, planning and global budgeting would rein in costs.”

Young noted that Obama has said more than once that he is a supporter of a single-payer universal health care program, and that if he were “starting from scratch,” he would favor adopting one. In 2003, Young said, then Illinois state Sen. Obama remarked that “first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”

Young remarked: “Tuesday’s election has made all of these conditions happen. In his first 100 days, President Obama has a window of opportunity to inspire the nation by championing the enactment of single-payer national health insurance under the slogan, ‘Everybody in, nobody out.’ Such a plan is embodied in the U.S. National Health Insurance Act, H.R. 676, introduced by Rep. John Conyers Jr. (D-Mich.) and co-sponsored by more than 90 others, more than any other health reform legislation.”

Young noted that at least five additional supporters of single-payer health reform were elected to Congress yesterday, including Senator-elect Tom Udall (D-N.M.), and that pro-single-payer ballot initiatives in 10 Massachusetts legislative districts “won by a landslide, on average receiving 73 percent of the vote.”

“Adopting a nationwide single-payer system will build on the great achievement of Medicare, further unify our people, strengthen our country’s economic competitiveness and assure President Obama’s legacy as an American hero,” Young said.

*****

Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, call (312) 782-6006 or visit www.pnhp.org/stateactions.

An analysis of Obama’s health care proposals by Dr. Don McCanne, senior health policy fellow at PNHP, can be found here.

A Kaiser Foundation interview with PNHP co-founder Dr. David Himmelstein about the elections and single-payer health reform can be found here.

The text of a recent “Open Letter to the Candidates on Single-Payer Health Reform,” signed by over 5,000 physicians, can be found here.

UK halts cancer drug penalty

Terminally ill patients to get expensive new drugs on NHS

By Rebecca Smith
Telegraph.co.uk
November 4, 2008
The NHS drugs rationing body the National Institute of health and Clinical Excellence (NICE) will be more flexible in deciding whether drugs for patients at the end of their lives are cost effective.
The move is a victory for campaigners who have argued that it is cruel to deny patients a drug that may extend their lives long enough to see a grandchild born, a daughter’s wedding or the last Christmas with their family.
Currently expensive drugs that prolong life by a few months often breach the cost effective threshold used by Nice.
Some patients want to “top up” their care by paying for these drugs privately only then to be told they forfeit all of their NHS care and must pay for the entirety of their treatment. This is often more than they can afford.
In a fundamental shift in the health service, ministers will announce that patients will now be allowed to buy drugs privately without giving up the right to having the rest of their care paid for by the NHS.
Ministers will admit there will be no financial help for poorer patients who cannot afford to top-up their NHS care.
Critics have said allowing top-ups will create a two-tier NHS and undermine the founding principles that care should be provided irrespective of ability to pay.
http://www.telegraph.co.uk/news/newstopics/politics/health/3374318/Terminally-ill-patients-to-get-expensive-new-drugs-on-NHS.html
And UK’s private insurers move in:
http://www.telegraph.co.uk/finance/personalfinance/insurance/3378442/Victory-for-cancer-patients-as-NHS-ban-on-top-up-drugs-is-lifted.html

There have been many reports from the U.S. opponents of government health programs proclaiming that “life saving drugs are denied” for cancer patients in UK’s NHS. Generally, these are cancer drugs which had been evaluated by the National Institute of Health and Clinical Excellence (NICE) and found to have very little benefit, if any, especially when considering the high prices of these drugs.
The patients could still use the drugs, but they would have to pay for them. Because of the concern that this would create a two-tiered system within the public NHS program, it was decided that patients electing to use these drugs would have to switch to the private sector for their full care. Thus the claim that the government program “denies life saving drugs.”
The decision was reversed when it was decided that individuals obtaining their care through the NHS should not be required to leave the public program merely because, in their desperation, they wanted to be able to purchase expensive drugs of only marginal or questionable benefit.
Most would agree that the public program should cover all beneficial health care services. But should public funds be used to pay for expensive care that provides negligible value, or may even be detrimental? NICE tries to sort these out so that taxpayers are not having to foot the bill for technological and therapeutic excesses that don’t help and may harm.
The private insurance industry in the UK already has been providing supplementary coverage for health care. This coverage duplicates the services of the NHS, but because of higher reimbursement rates allows beneficiaries a greater choice of private care options, and allows them to move into the front of the queue. This has created an explicit two-tiered system in the UK, with underfunding and excessive waiting periods in the public sector. This is precisely why other nations such as Canada prohibit supplementary insurance.
On the other hand, complementary insurance is used to cover health care that is not provided by the public sector, such as drug benefits and foreign travel coverage for Canadians. This decision in the UK to allow non-covered private options for public NHS patients has opened up the market for complementary insurance in the UK, and the insurers are moving in.
The single payer model supported by PNHP would prohibit supplementary insurance, but would allow complementary insurance for services such as hospital suites or non-essential cosmetic surgery that taxpayers should not be required to finance.
The WHO has published an excellent report on private insurance and cost sharing (35 pages): What are the equity, efficiency, cost containment and choice implications of private health-care funding in western Europe?
http://www.euro.who.int/document/e83334.pdf

UK halts cancer drug penalty

Terminally ill patients to get expensive new drugs on NHS

By Rebecca Smith
Telegraph.co.uk
November 4, 2008

The NHS drugs rationing body the National Institute of health and Clinical Excellence (NICE) will be more flexible in deciding whether drugs for patients at the end of their lives are cost effective.

The move is a victory for campaigners who have argued that it is cruel to deny patients a drug that may extend their lives long enough to see a grandchild born, a daughter’s wedding or the last Christmas with their family.

Currently expensive drugs that prolong life by a few months often breach the cost effective threshold used by Nice.

Some patients want to “top up” their care by paying for these drugs privately only then to be told they forfeit all of their NHS care and must pay for the entirety of their treatment. This is often more than they can afford.

In a fundamental shift in the health service, ministers will announce that patients will now be allowed to buy drugs privately without giving up the right to having the rest of their care paid for by the NHS.

Ministers will admit there will be no financial help for poorer patients who cannot afford to top-up their NHS care.

Critics have said allowing top-ups will create a two-tier NHS and undermine the founding principles that care should be provided irrespective of ability to pay.

http://www.telegraph.co.uk/news/newstopics/politics/health/3374318/Terminally-ill-patients-to-get-expensive-new-drugs-on-NHS.html

And UK’s private insurers move in:
http://www.telegraph.co.uk/finance/personalfinance/insurance/3378442/Victory-for-cancer-patients-as-NHS-ban-on-top-up-drugs-is-lifted.html

Comment:

By Don McCanne, MD

There have been many reports from the U.S. opponents of government health programs proclaiming that “life saving drugs are denied” for cancer patients in UK’s NHS. Generally, these are cancer drugs which had been evaluated by the National Institute of Health and Clinical Excellence (NICE) and found to have very little benefit, if any, especially when considering the high prices of these drugs.

The patients could still use the drugs, but they would have to pay for them. Because of the concern that this would create a two-tiered system within the public NHS program, it was decided that patients electing to use these drugs would have to switch to the private sector for their full care. Thus the claim that the government program “denies life saving drugs.”

The decision was reversed when it was decided that individuals obtaining their care through the NHS should not be required to leave the public program merely because, in their desperation, they wanted to be able to purchase expensive drugs of only marginal or questionable benefit.

Most would agree that the public program should cover all beneficial health care services. But should public funds be used to pay for expensive care that provides negligible value, or may even be detrimental? NICE tries to sort these out so that taxpayers are not having to foot the bill for technological and therapeutic excesses that don’t help and may harm.

The private insurance industry in the UK already has been providing supplementary coverage for health care. This coverage duplicates the services of the NHS, but because of higher reimbursement rates allows beneficiaries a greater choice of private care options, and allows them to move into the front of the queue. This has created an explicit two-tiered system in the UK, with underfunding and excessive waiting periods in the public sector. This is precisely why other nations such as Canada prohibit supplementary insurance.

On the other hand, complementary insurance is used to cover health care that is not provided by the public sector, such as drug benefits and foreign travel coverage for Canadians. This decision in the UK to allow non-covered private options for public NHS patients has opened up the market for complementary insurance in the UK, and the insurers are moving in.

The single payer model supported by PNHP would prohibit supplementary insurance, but would allow complementary insurance for services such as hospital suites or non-essential cosmetic surgery that taxpayers should not be required to finance.

The WHO has published an excellent report on private insurance and cost sharing (35 pages): What are the equity, efficiency, cost containment and choice implications of private health-care funding in western Europe?

http://www.euro.who.int/document/e83334.pdf

It is time for Medicare for all

By Ahmed Kutty
Kearney Hub
11/03/2008

With an economic meltdown under way and a new president and a new Congress about to be in charge of our country, time is now for Americans to demand a publicly funded health care financing system of universal, comprehensive and equitable coverage against illness.

The U.S. Constitution confers the responsibility “to form a more perfect union … , promote the general welfare and secure the blessings of liberty,” on our elected government.

Our current system of financing health care costs has been very inefficient, terribly expensive and often unresponsive to the needs of the people when stricken by illness, primarily because it is a for-profit, investor-owned and a fragmented-patchwork system, but with the singular exception of Medicare, which is run as a non-profit service-oriented organization for Americans over age 65.

It’s overhead is in the single digits, while in the private system approximately 35 cents out of each health care dollar is spent on the company expenses, including exorbitant CEO salaries, and only 65 cents per premium dollar is available for direct patient care expenses.

The SCHIP program for children was a success until its recent demise by defunding. For working-age Americans, keeping health care insurance as an employer responsibility has been a failure, both for the employees and the employers, including big corporations and small-business owners, with skyrocketing costs making them non-competitive in a globalizing world, especially the industrialized world where some version of a publicly funded health care system is available to all their citizens.

The United States is the lone outlier in this context.

Medicare is not for free, as the free-market fundamentalists would have us believe, nor is it government run. Just as for the private insurance plans, everyone pays a premium via the federal withholding tax and after age 65, the premium is billed directly to the beneficiaries of the program.

Choice of doctors and hospitals has never been fettered, ever since President Lyndon Johnson signed the law in the fall of 1965. Over the past 40-plus years with modifications and regulations put in place, the program is enormously popular with senior Americans, and is a success story.

This was a part fulfillment of President Harry Truman’s effort to introduce a national health care system in the late 1940s and represented a belated big step toward what FDR called “a minimum of the promise that we can offer to the American people” in his address to Congress as it adjourned in December 1933.

Now fast forward to the early Bill Clinton presidency and we find an attempt to introduce a national health care insurance system, under Hillary Clinton’s leadership, fail for lack of political will.

This fall the California Legislature passed a bill, SB840, piloted by state Sen. Sheila Kuehl, providing for an expanded Medicare for all-style single-payer health insurance plan, only to be vetoed by Gov. Arnold Schwarznegger.

This time, we the people should settle for nothing less than a comprehensive national single-payer system, which means Medicare for all. We must work to create a constituency to get the necessary legislation passed by the next Congress and signed by the new president, regardless of party affiliation.

This year’s momentous election will have a long-lasting positive effect on the crisis of health care financing, a major concern of the electorate, if the next Congress takes up the proposal/bill that Sen. Ted Kennedy, from his sick bed is working on, behind closed doors in the Dirksen Senate Office building, a measure Kennedy called, “the cause of my life.”

We shall have them not resuscitate the current failed system, and we will forge the political will necessary for our elected leaders to do the right thing, by raising the voice of an aroused public conscience, that shall be heard loud and clear in the corridors of power.

As true patriots, we will have them treat health care as a right, not a privilege, and not as a commodity but as part of our social compact. Surely a bulwark of “the American Dream” must include a measure of security against vagaries of illness, collectively provided, with risk spread over three hundred million Americans, in this great nation of ours, the most affluent on the earth.

Ahmed Kutty, MD, FACC, of Kearney is a member of the American College of Physicians, which supports the single payer plan.

Choices in coverage during open enrollment

Health insurance shoppers, be wise

By Bobby Caina Calvan
The Sacramento Bee
November 3, 2008
For those fortunate enough to have health insurance, let the head scratching begin (during open enrollment): Option 1 or Option 2? Routine, Choice or Select? PPO or HMO?
Experts say the year-end ritual is an oft-neglected process that deserves focused consideration from consumers, many of whom race through the insurance paperwork with utter terror.
Their decisions have far-reaching consequences.
“It can become a very expensive mistake if they go eenee, meenee, mynee, moe,” said Patricia Feathers, a customer service agent at Placer West Insurance Services in Lincoln. “Making the right choice means staving off bankruptcy and getting the right coverage.”
An ill-informed decision during open enrollment is usually locked in for a year, sometimes more.
But only one in 10 people express confidence in their understanding of their health coverage, according to another survey by the insurer CIGNA.
“When I talk to people, the problem over and over again is that people don’t have the knowledge they need to make an informed decision,” said Karen Kocher, CIGNA’s chief learning officer.
Employees often “default into their existing plans, opt for the cheapest plan, thinking they will save money in the long run.”
The better strategy, experts say, is to have a realistic assessment of health care needs, including an honest look at where health care dollars were spent in the previous year.
http://www.sacbee.com/101/story/1365091.html

What health insurance coverage will you need next year? Do you determine that by taking an honest look at where health care dollars were spent in the previous year? You are healthy, your health care spending has been negligible, so do you opt for the least expensive plan?
What about next year? Will you have a heart attack? Will you rupture an intracranial aneurysm and require prolonged rehabilitation services? Will you experience the onset of diabetes? Will an unpredictable accident result in extensive injuries, perhaps with permanent neurological impairment? Will you develop an autoimmune disease such as lupus? Multiple sclerosis? Will you develop cancer? If so, which cancer and how involved and protracted will the treatment program be?
Next year’s medical catastrophe, whether acute or chronic, can belong to any of us. That is why everyone of us requires a program that would enable us to access the health care that we need without having to face a financial catastrophe as well. That is a program that everyone would want, if they could afford it.
So why do 90 percent of people lack confidence in understanding their health coverage options? Well, they are confusing. None of the options offer full coverage for everything. All of them attempt to keep the premiums affordable by reducing what is covered. There are endless variations in lists of authorized providers, benefits covered, deductibles, co-payments, coinsurance, tiering, payment caps, and other features that are impossible to sort out when you don’t even know what your needs will be.
What they have in common is that they all decrease, to varying degrees, the security that your health care coverage will provide. You are asked to place a bet now. A larger wager will provide somewhat more security, but none of that wager can be recovered if you end up not needing medical care, which makes you pause before you select that option. (HSAs are not an exception since they are merely segregated savings accounts and not pooled-risk funds; someone else’s HSA would not pay your medical bills.) A smaller wager puts less of a crimp in your budget, but at the cost of losing the security of not being exposed to significant medical debt should the need for care arise.
When all of us want a plan that will provide us with the care that we need, when we need it, without having to face financial penalties for being sick or injured, we really need only one day of open enrollment: the day that we are born. That is the day that each of us would be enrolled in a single payer national health program that is open to all of us forever.

Choices in coverage during open enrollment

Health insurance shoppers, be wise

By Bobby Caina Calvan
The Sacramento Bee
November 3, 2008

For those fortunate enough to have health insurance, let the head scratching begin (during open enrollment): Option 1 or Option 2? Routine, Choice or Select? PPO or HMO?

Experts say the year-end ritual is an oft-neglected process that deserves focused consideration from consumers, many of whom race through the insurance paperwork with utter terror.

Their decisions have far-reaching consequences.

“It can become a very expensive mistake if they go eenee, meenee, mynee, moe,” said Patricia Feathers, a customer service agent at Placer West Insurance Services in Lincoln. “Making the right choice means staving off bankruptcy and getting the right coverage.”

An ill-informed decision during open enrollment is usually locked in for a year, sometimes more.

But only one in 10 people express confidence in their understanding of their health coverage, according to another survey by the insurer CIGNA.

“When I talk to people, the problem over and over again is that people don’t have the knowledge they need to make an informed decision,” said Karen Kocher, CIGNA’s chief learning officer.

Employees often “default into their existing plans, opt for the cheapest plan, thinking they will save money in the long run.”

The better strategy, experts say, is to have a realistic assessment of health care needs, including an honest look at where health care dollars were spent in the previous year.

http://www.sacbee.com/101/story/1365091.html

Comment:

By Don McCanne, MD

What health insurance coverage will you need next year? Do you determine that by taking an honest look at where health care dollars were spent in the previous year? You are healthy, your health care spending has been negligible, so do you opt for the least expensive plan?

What about next year? Will you have a heart attack? Will you rupture an intracranial aneurysm and require prolonged rehabilitation services? Will you experience the onset of diabetes? Will an unpredictable accident result in extensive injuries, perhaps with permanent neurological impairment? Will you develop an autoimmune disease such as lupus? Multiple sclerosis? Will you develop cancer? If so, which cancer and how involved and protracted will the treatment program be?

Next year’s medical catastrophe, whether acute or chronic, can belong to any of us. That is why everyone of us requires a program that would enable us to access the health care that we need without having to face a financial catastrophe as well. That is a program that everyone would want, if they could afford it.

So why do 90 percent of people lack confidence in understanding their health coverage options? Well, they are confusing. None of the options offer full coverage for everything. All of them attempt to keep the premiums affordable by reducing what is covered. There are endless variations in lists of authorized providers, benefits covered, deductibles, co-payments, coinsurance, tiering, payment caps, and other features that are impossible to sort out when you don’t even know what your needs will be.

What they have in common is that they all decrease, to varying degrees, the security that your health care coverage will provide. You are asked to place a bet now. A larger wager will provide somewhat more security, but none of that wager can be recovered if you end up not needing medical care, which makes you pause before you select that option. (HSAs are not an exception since they are merely segregated savings accounts and not pooled-risk funds; someone else’s HSA would not pay your medical bills.) A smaller wager puts less of a crimp in your budget, but at the cost of losing the security of not being exposed to significant medical debt should the need for care arise.

When all of us want a plan that will provide us with the care that we need, when we need it, without having to face financial penalties for being sick or injured, we really need only one day of open enrollment: the day that we are born. That is the day that each of us would be enrolled in a single payer national health program that is open to all of us forever.