PNHP

Anthem intercepting and redirecting imaging referrals

Anthem intercepting and redirecting imaging referrals

Need an MRI? Anthem might have a deal for you

By Shari Rudavsky
IndyStar.com
January 30, 2011

… an Anthem Blue Cross and Blue Shield pilot program made its debut in December. Under the program, an Anthem employee calls policyholders who have been approved for scans and lets them know whether a cheaper, high-quality option exists close to them. If the policyholder agrees, Anthem sets up the appointment.

Anthem officials say they designed the program to steer their patients toward higher-quality facilities that charge less. But some say more emphasis is being placed on costs and not on quality of care and consequences for the patient.

The program is currently limited to Central Indiana policyholders scheduled for imaging such as MRI and CT scans. Still, it could usher in a major change in health care in which insurers work directly with policyholders to keep costs low for a variety of medical services.

“This puts a lot more control in the hands of the individual consumer and allows the consumer to make a decision that is a good one,” said Susan Pisano, a spokeswoman for the Association of Health Insurance Plans. “I think you’re going to see this kind of program more and more in the short term.”

If the program proves successful, the company might explore the idea of similar programs for lab tests or colonoscopies.

http://www.indystar.com/article/20110131/BUSINESS/101310327

Comment: 

By Don McCanne, MD

WellPoint’s Anthem Blue Cross and Blue Shield subsidiaries have led the health insurance industry in innovation, but these innovations have been designed to improve their business model and profits, not to improve health care. Even though regulatory oversight of the insurers should increase as a result of enactment of the Patient Protection and Affordable Care Act, this new innovation of intercepting and redirecting patient referrals reveals that the private, for-profit insurance industry has every intention expanding the range of self-serving innovations that increase profits as long as the innovations fall below the threshold that would induce a patient backlash.

There are a great many reasons why a physician may select one imaging center over another for the patient’s procedure. The decision may be based on the quality of the equipment or the skills of the radiologist’s team. It may be based on prior positive or negative experiences with the centers. It may be based on integrated eHealth systems. It may be based on specific procedures not utilized in all centers. Regardless, these are clinical decisions that should be made by physicians who have their patients’ health care needs first and foremost in their minds.

(Physicians also may selectively refer to their own imaging centers – a conflict of interest that is another problem, though not covered in today’s message.)

When the insurer intercepts and redirects a referral, it is done to reduce the insurer’s costs. The insurer may claim that the intervention is to direct the patient to higher quality services, but the referring physician should be in a much better position to make that judgement. No, the decision is made on the basis of, “It’s the prices, stupid.”

The problem that the insurers are addressing is very real. Prices do vary tremendously, especially between facilities that are contracted with the insurer and those that are not. This raises the extremely important point that a health care financing system based on multiple private insurers acting independently cannot possibly bring us appropriate, reasonable pricing throughout the entire health care delivery system.

Of course, this is one of the more important advantages of a single payer system. Prices are not based on secret contracts and dysfunctional markets; instead they are based on negotiation with a public administrator, taking into consideration legitimate costs and fair profits. The interests of patients are served by preventing excessively high prices that waste taxpayer funds while providing adequate payment to ensure that the health care professions will remain attractive to well qualified individuals. The private insurance industry will never get this right.

Single-payer system would save money and lives

By Richard Weiskopf, M.D.
Letters, The Post-Standard (Syracuse, N.Y.), Jan. 23, 2011
 
With all the discussion about health care reform, including Rep. Ann Marie Buerkle’s (R-N.Y.) advocating repeal, I would like to cite three points researched and published (but not publicized enough) by Physicians for a National Health Program, which continues to advocate for national single-payer reform, and of which I am a member.
 
1. Administrative costs consume 31 percent of U.S. health spending, most of it unnecessary. The United States could save enough on administrative expenses (nearly $400 billion annually) with a single-payer system to cover all the uninsured.
 
2. Medical bills contribute to more than 60 percent of all bankruptcies. Three-fourths of those bankrupted had health insurance at the time they got sick.
 
3. Nearly 45,000 Americans die each year from lack of health insurance. The uninsured do not receive all the medical care they need – the live sicker and die younger. Those most in need of preventive services are least likely to receive them.

Anthem intercepting and redirecting imaging referrals

Need an MRI? Anthem might have a deal for you

By Shari Rudavsky
IndyStar.com
January 30, 2011

… an Anthem Blue Cross and Blue Shield pilot program made its debut in December. Under the program, an Anthem employee calls policyholders who have been approved for scans and lets them know whether a cheaper, high-quality option exists close to them. If the policyholder agrees, Anthem sets up the appointment.

Anthem officials say they designed the program to steer their patients toward higher-quality facilities that charge less. But some say more emphasis is being placed on costs and not on quality of care and consequences for the patient.

The program is currently limited to Central Indiana policyholders scheduled for imaging such as MRI and CT scans. Still, it could usher in a major change in health care in which insurers work directly with policyholders to keep costs low for a variety of medical services.

“This puts a lot more control in the hands of the individual consumer and allows the consumer to make a decision that is a good one,” said Susan Pisano, a spokeswoman for the Association of Health Insurance Plans. “I think you’re going to see this kind of program more and more in the short term.”

If the program proves successful, the company might explore the idea of similar programs for lab tests or colonoscopies.

http://www.indystar.com/article/20110131/BUSINESS/101310327

WellPoint’s Anthem Blue Cross and Blue Shield subsidiaries have led the health insurance industry in innovation, but these innovations have been designed to improve their business model and profits, not to improve health care. Even though regulatory oversight of the insurers should increase as a result of enactment of the Patient Protection and Affordable Care Act, this new innovation of intercepting and redirecting patient referrals reveals that the private, for-profit insurance industry has every intention expanding the range of self-serving innovations that increase profits as long as the innovations fall below the threshold that would induce a patient backlash.

There are a great many reasons why a physician may select one imaging center over another for the patient’s procedure. The decision may be based on the quality of the equipment or the skills of the radiologist’s team. It may be based on prior positive or negative experiences with the centers. It may be based on integrated eHealth systems. It may be based on specific procedures not utilized in all centers. Regardless, these are clinical decisions that should be made by physicians who have their patients’ health care needs first and foremost in their minds.

(Physicians also may selectively refer to their own imaging centers – a conflict of interest that is another problem, though not covered in today’s message.)

When the insurer intercepts and redirects a referral, it is done to reduce the insurer’s costs. The insurer may claim that the intervention is to direct the patient to higher quality services, but the referring physician should be in a much better position to make that judgement. No, the decision is made on the basis of, “It’s the prices, stupid.”

The problem that the insurers are addressing is very real. Prices do vary tremendously, especially between facilities that are contracted with the insurer and those that are not. This raises the extremely important point that a health care financing system based on multiple private insurers acting independently cannot possibly bring us appropriate, reasonable pricing throughout the entire health care delivery system.

Of course, this is one of the more important advantages of a single payer system. Prices are not based on secret contracts and dysfunctional markets; instead they are based on negotiation with a public administrator, taking into consideration legitimate costs and fair profits. The interests of patients are served by preventing excessively high prices that waste taxpayer funds while providing adequate payment to ensure that the health care professions will remain attractive to well qualified individuals. The private insurance industry will never get this right.

Medicaid is constitutional; mandate isn't

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA PENSACOLA DIVISION

STATE OF FLORIDA, by and through Attorney General Pam Bondi, et al.;
Plaintiffs,
v.
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, et al.,
Defendants.

ORDER GRANTING SUMMARY JUDGMENT

I. Medicaid Expansion (Count Four)

Accordingly, summary judgment must be granted in favor of the defendants on Count IV.

II. Individual Mandate (Count One)

The individual mandate is outside Congress’ Commerce Clause power, and it cannot be otherwise authorized by an assertion of power under the Necessary and Proper Clause. It is not Constitutional. Accordingly, summary judgment must be granted in favor of the plaintiffs on Count I.

I must conclude that the individual mandate and the remaining provisions are all inextricably bound together in purpose and must stand or fall as a single unit. The individual mandate cannot be severed.

Injunction

Thus, the award of declaratory relief is adequate and separate injunctive relief is not necessary.

Conclusion

For the reasons stated, I must reluctantly conclude that Congress exceeded the bounds of its authority in passing the Act with the individual mandate. That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system. The health care market is more than one sixth of the national economy, and without doubt Congress has the power to reform and regulate this market. That has not been disputed in this case. The principal dispute has been about how Congress chose to exercise that power here.

Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void.

For all the reasons stated above and pursuant to Rule 56 of the Federal Rules of Civil Procedure, the plaintiffs’ motion for summary judgment (doc. 80) is hereby GRANTED as to its request for declaratory relief on Count I of the Second Amended Complaint, and DENIED as to its request for injunctive relief; and the defendants’ motion for summary judgment (doc. 82) is hereby GRANTED on Count IV of the Second Amended Complaint.

In accordance with Rule 57 of the Federal Rules of Civil Procedure and Title 28, United States Code, Section 2201(a), a Declaratory Judgment shall be entered separately, declaring “The Patient Protection and Affordable Care Act” unconstitutional.

DONE and ORDERED this 31st day of January, 2011.

ROGER VINSON
Senior United States District Judge

Comment: 

By Don McCanne, MD

Judge Roger Vinson has ruled that the individual mandate in the Patent Protection and Affordable Care Act is unconstitutional, as Judge Henry Hudson had ruled earlier. Judge Vinson went further and ruled that the individual mandate cannot be severed from the rest of the Act, and, therefore, the entire Patent Protection and Affordable Care Act is unconstitutional.

He also ruled that “officials of the Executive Branch will adhere to the law as declared by the court. As a result, the declaratory judgment is the functional equivalent of an injunction.”

There are two fundamental decisions in this summary judgement:

1) The individual mandate to purchase private health insurance is unconstitutional. Since he has ruled that the mandate cannot be separated from the rest of the Act, the entire Act is unconstitutional.

2) Medicaid is constitutional. Summary judgement in support of Medicaid expansion was granted on behalf of the United States Department of Health and Human Services.

Forget the Supreme Court. Let’s walk away from the unconstitutional Patient Protection and Affordable Care Act and instead enact the constitutional Expanded and Improved Medicare for All Act. It’s less expensive, works better, and includes all of us.

As Judge Vinson stated, “That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system.”

Single payer: the only way to address the financial burden of Medicaid

The following statement was prepared for the NY Metro chapter of Physicians for a National Health Program and Single Payer New York by Leonard Rodberg, Ph.D., research director of the NY Metro chapter of PNHP, in response to Gov. Andrew Cuomo’s call for “Redesigning the Medicaid Program.”

By Leonard Rodberg

We all know that New York State’s health care system, like that of the rest of the nation, has serious problems, the large number of uninsured and the continually escalating costs being high among them. But it also has gross inequities in access, serious deficiencies in primary and preventive care, and wasteful inefficiencies in the use of our health care resources, making our health care among the most expensive in the nation. All of this can be traced to the fragmented, inefficient and wasteful way we pay for health care.

Driven in large part by the rising cost of health care, the nation has accepted the goal of universal coverage. The recently passed national legislation seeks to achieve this, but it is now widely recognized that, aside from some as-yet-undefined demonstration projects, it does little to contain the rising cost of care.

The truth is that the entire system of private insurance for the working population, supplemented by public programs for the poor and the elderly, has become unaffordable. It is incapable of assuring access for everyone or of stemming the mounting cost of care. Further, numerous studies have shown that it adds as much as 30 percent to the cost of care through unnecessary and duplicative billing, marketing, profit, and administrative costs of both insurers and providers.

New York State’s Medicaid program is both a cause and a victim of this bloated cost structure. It is often described as the most generous in the country. Coming out of the progressive tradition of this state, it has sought to remedy, within our state, a host of deficiencies in our national health care system: (1) we don’t discriminate on the basis of immigration status, (2) we have pushed the limits for coverage considerably above the poverty level for children and pregnant women, and (3) we cover a great deal of long-term care (about half of Medicaid spending in the state is for this most expensive form of care).

Pushed most recently by the impact of the recession, our Medicaid enrollment has grown from 2.8 million in 2001 to 4.7 million today. It now pays for the health care of nearly a quarter of our population – and a million more people are eligible for its coverage but have not enrolled. Medicaid spending rose from $29.6 billion in 2001 to more than $50 billion today, climbing at a rate exceeding 6 percent per year over the decade. This is twice the general rate of inflation and is similar to the rate at which all health care costs have been rising across the country.

Furthermore, today there are 2.6 million people without insurance of any kind in this state. Of these, about 1.1 million people are eligible today for Medicaid but have not enrolled. According to a study released several months ago by the NYS Health Foundation, the federal health reform will, by 2014, cause between 800,000 and 1.2 million additional people to become insured, partly under Medicaid and partly through access to subsidized private insurance. However, by their estimate, there will still be between 660,000 and 1 million people eligible for Medicaid but still not enrolled, along with 800,000 more (including undocumented immigrants) who could purchase insurance but will not, and thus will remain uninsured. These people will, however, continue to use health care services, albeit at a reduced rate – generally, the uninsured use about half the medical services that the insured do – but they will also not be paying into the system.

The leaders and citizens of our state need to think much more broadly if we want to address seriously our increasingly unaffordable health care system. Merely looking for savings within the Medicaid system will not halt the rising costs of the system in which it is embedded.

Numerous studies conducted over the last two decades have shown that a wide variety of substantial savings will accrue through implementation of a single-payer system. There will be savings in provider spending, in insurer administrative costs, and through improved coordination and more efficient purchasing of medical supplies and services. As just one example, the entire apparatus for determining who is eligible for Medicaid, Family Health Plus, and Child Health Plus would become unnecessary – everyone would be in the same pool as a right of residency in the state.

The Primary Care Coalition, a grouping of the principal organized primary care providers in the state, has estimated that overall state spending on health care could be reduced by $10 billion (or 6 percent of the total bill) through enhanced access to modern, coordinated primary care. Much of the spending on expensive in-patient care and medical treatments could be reduced or eliminated if robust primary care to be were available in every community. Achieving this can best be accomplished in the kind of coordinated planning environment that a unified single-payer system would make possible.

All of the studies indicate that all of these savings will more than offset the cost of the additional health care services provided in a unified system where everyone is covered. In fact, a study just completed in Vermont has found that nearly a quarter of current expenditures in that state could be saved through adoption of a single-payer plan, coupled with reforms to the health care delivery system.

What, then, would happen if we were to adopt in New York a publicly funded single-payer system, similar to what the state of Vermont is considering today? First, we assume that the federal government would continue to contribute what it has been spending on Medicare and Medicaid in New York State (all of Medicare and half of Medicaid spending). The state would continue to contribute sums comparable with what it now spends on Medicaid, but for reasons suggested below, these would grow much more slowly. Then, because everyone who is working or has an income would be paying, via taxes, into the system, there would be billions of dollars that are unavailable today, when so many businesses and individuals opt out of purchasing health insurance. So there would be more sources of revenue in the system, but also very substantial savings as well.

Most important, cost growth could be contained within such a system through a unified budgeting and expenditure system. If, as some have suggested, costs were to be constrained to rise at no more than 1 percent above the general rate of inflation, this would lead to billions of dollars in savings for New York State within a few years.

Following the example of our neighboring state in Vermont, New York State should fund a detailed study of the alternatives for achieving universal coverage, including alternatives embodying single-payer principles. (Everyone recognizes that the “Analysis of Reform Options” conducted under a legislative mandate and published in July 2009 failed to look in sufficient depth at the alternatives for achieving universal coverage and did not provide enough information to be useful for policy decisions.) The state should commission a study similar to the one just completed in Vermont, giving detailed specifications on the types of financing systems that might be introduced, together with comprehensive and explicit computations of their costs and savings.

Trying to solve Medicaid’s problems by looking only at the Medicaid program will not work. Only a re-examination of the way we pay for our entire health care system will provide the answers to the financial dilemmas facing New York State.

Medicaid is constitutional; mandate isn’t

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA PENSACOLA DIVISION

STATE OF FLORIDA, by and through Attorney General Pam Bondi, et al.;
Plaintiffs,
v.
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, et al.,
Defendants.

ORDER GRANTING SUMMARY JUDGMENT

I. Medicaid Expansion (Count Four)

Accordingly, summary judgment must be granted in favor of the defendants on Count IV.

II. Individual Mandate (Count One)

The individual mandate is outside Congress’ Commerce Clause power, and it cannot be otherwise authorized by an assertion of power under the Necessary and Proper Clause. It is not Constitutional. Accordingly, summary judgment must be granted in favor of the plaintiffs on Count I.

I must conclude that the individual mandate and the remaining provisions are all inextricably bound together in purpose and must stand or fall as a single unit. The individual mandate cannot be severed.

Injunction

Thus, the award of declaratory relief is adequate and separate injunctive relief is not necessary.

Conclusion

For the reasons stated, I must reluctantly conclude that Congress exceeded the bounds of its authority in passing the Act with the individual mandate. That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system. The health care market is more than one sixth of the national economy, and without doubt Congress has the power to reform and regulate this market. That has not been disputed in this case. The principal dispute has been about how Congress chose to exercise that power here.

Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void.

For all the reasons stated above and pursuant to Rule 56 of the Federal Rules of Civil Procedure, the plaintiffs’ motion for summary judgment (doc. 80) is hereby GRANTED as to its request for declaratory relief on Count I of the Second Amended Complaint, and DENIED as to its request for injunctive relief; and the defendants’ motion for summary judgment (doc. 82) is hereby GRANTED on Count IV of the Second Amended Complaint.

In accordance with Rule 57 of the Federal Rules of Civil Procedure and Title 28, United States Code, Section 2201(a), a Declaratory Judgment shall be entered separately, declaring “The Patient Protection and Affordable Care Act” unconstitutional.

DONE and ORDERED this 31st day of January, 2011.

ROGER VINSON
Senior United States District Judge

Judge Roger Vinson has ruled that the individual mandate in the Patent Protection and Affordable Care Act is unconstitutional, as Judge Henry Hudson had ruled earlier. Judge Vinson went further and ruled that the individual mandate cannot be severed from the rest of the Act, and, therefore, the entire Patent Protection and Affordable Care Act is unconstitutional.

He also ruled that “officials of the Executive Branch will adhere to the law as declared by the court. As a result, the declaratory judgment is the functional equivalent of an injunction.”

There are two fundamental decisions in this summary judgement:

1) The individual mandate to purchase private health insurance is unconstitutional. Since he has ruled that the mandate cannot be separated from the rest of the Act, the entire Act is unconstitutional.

2) Medicaid is constitutional. Summary judgement in support of Medicaid expansion was granted on behalf of the United States Department of Health and Human Services.

Forget the Supreme Court. Let’s walk away from the unconstitutional Patient Protection and Affordable Care Act and instead enact the constitutional Expanded and Improved Medicare for All Act. It’s less expensive, works better, and includes all of us.

As Judge Vinson stated, “That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system.”

Physicians for a National Health Program Tour Oregon to Promote Single Payer Health Care

February 2011  

The Oregon Chapter of Physicians for a National Health Program (PNHP) and Mad As Hell Doctors (MAHD) will follow up on their landmark 2009 national tour and 2010 California tours with spirited rallies in Linn and Lincoln Counties during February. Their program will feature music by local musicians and the audience (singing); documentary videos by Paul Hochfeld M.D.; testimony by physicians and nurses; and “Mad As Heck Minutes” by audience members on screen.  

Albany, Feb. 13, 6:30-8:00 p.m.       
Albany Senior Center, 489 Water Ave.  
Contact:  Edie Orner, ediestewart29@msn.com

Eugene, Feb. 14, 6:30-8:00 p.m.     
U of O campus, To Be Announced   
Contact:  Charlotte Maloney, charuhc@comcast.net

Florence, Feb. 15, 6:30-8:00 p.m.      
Siuslaw Public Library, 1460 9th St.  
Contact:  Rand Dawson, rdawson@oregonfast.net

Yachats, Feb. 16, 2:00-4:00 p.m.      
Yachats Commons, Hwy. 101 & W. 4th St. 
Contact:  Max Glenn, m35glenn@peak.org

Newport, Feb. 16, 7:00-9:00 p.m.     
Visual Arts Center, 777NW Beach Dr. 
Contact:  Joan Cvar, cvar@peak.org

Lincoln City, Feb. 17,  6:30-8:00 p.m.      
St. Augustine’s Catholic Church, 1139 NW Hwy. 101 
Contact:  Libby Durbin, ldbelle@embarqmail.com
Contact:  Paco Maribono, frankeyus@yahoo.com

TBA 
Salem, March 17 
Grants Pass, March 26 
Medford, March 27 
Ashland, March 27 
Brookings, March 28     
Bandon, March 29 
Coos Bay, March 30 
Roseburg, March 31  

PNHP-Oregon and Mad As Hell Doctors are physicians, nurses, ancillary health providers, and other concerned citizens advocating for an improved and expanded Medicare program to provide financially sustainable universal health coverage for all Americans. In September 2009, a PNHP/MAHD crew traveled 6,000 miles through America’s heartland from Portland, OR to Washington, D.C., stopping at over 40 venues in 22 states. After appearances on the Ed Schultz Show (MSNBC), Keith Olberman (MSNBC), Democracy Now! and interviews on dozens of other media outlets, the group is continuing its unique approach and activist flair to advocate for Single Risk Pool, Improved Medicare-for-all.   

PNHP/MAHD contends that the Patient Protection and Affordable Care Act (P-PACA) does too little to protect the health and livelihood of patients and their families. P-PACA serves to further entrench the current medical-industrial complex with an unsustainable cost spiral within our health care system.PNHP further contends that, while the Oregon Health Policy Board, a result of House Bill 2009, has proposed critical improvements in Oregon’s health care system, these improvements will be achievable only under a Single Risk Pool, Improved Medicare-for-all plan.  

PNHP is hitting the road again over the next several months to carry its message throughout Oregon. More information is available at https://pnhp.org/states/oregon and www.madashelldoctors.com.   

You can also interact with 11,000 friends on www.facebook.com/MadDrs.    

Mike Huntington, Physicians for a National Health Program, (541) 745-5635, mchuntington@comcast.net

California insurers deny 26 percent of all claims

State’s 7 largest rejected 67.5 million claims since 2002

California Nurses Association
Press Release
Jan. 31, 2011
 
Despite the passage of national health care reform and widespread uproar in California over insurance industry pricing practices and other abuses, California’s largest private insurance companies continue to deny more than one-fourth of all claims, according to new findings released today by the California Nurses Association/National Nurses United.
 
Blue Shield, which has recently garnered attention for pushing through premium rate hikes of up to 59 percent for individuals in California, denied nearly 2 million claims last year, trailing only Anthem Blue Cross, which denied nearly 6 million claims. PacifiCare had the highest percentage of denials at a shocking 44 percent.
 
Nurses, patients, and consumer advocates will cite the data, along with the widely criticized pricing practices of Blue Shield and other insurers, at a protest Tuesday at the San Francisco headquarters of Blue Shield, at 50 Beale St, at 11 a.m.
 
For the first three quarters of 2010, seven California insurance giants rejected 13.1 million claims, 26 percent of all claims submitted, a number only slightly below the 26.8 percent rate for 2009. The data, new findings by the Institute of Health and Socio-Economic Policy, the CNA/NNU research arm, is based on data from the California Department of Managed Care.
 
Claims denial rates by leading California insurers, first three quarters, 2010:
 
–  PacifiCare — 43.9 percent
 
–  Cigna – 39.6 percent
 
–  Anthem Blue Cross – 27.3 percent
 
–  HealthNet – 24.1 percent
 
–  Blue Shield – 21.9 percent
 
–  Kaiser Permanente – 20.2 percent
 
–  Aetna – 5.9 percent
 
Since 2002, these seven firms, which account for more than three-fourths of all insurance enrollees in California, have rejected 67.5 million claims. Claims denials generally refer to insurance payment rejections – which far too often puts patients on the hook for payment to the provider whose claim is rejected.
 
Cigna, which denied 40 percent of claims, showed the biggest increase from 2009, increasing its rejection rate by 5.3 percent. Kaiser Permanente accounted for the biggest drop, a one year decline of 7.4 percent in denials. Blue Shield, which has attracted recent notoriety for its individual premium rate hikes of up to 59 percent, slightly increased its denial rate by .3 percent from 2009.
 
“These rejection rates demonstrate one reason medical bills are a prime source of personal bankruptcies as doctors and hospitals will push patients and their families to make up what the insurer denies,” said CNA/NNU Co-President DeAnn McEwen. The national reform law signed by President Obama last spring has, to date, had no impact on the high pace of insurance denials, she noted.
 
“The denials also illustrate the appalling degree of bureaucracy in a wasteful system; for all the handwringing about ‘government’ health care, a real public program like Medicare is far less wasteful than the bloated private system that so casually rejects such a high number of medical claims,” McEwen said.
 
Following past CNA/NNU reports on denials, insurance industry representatives offered the specious response that they pay most “eligible” claims.
 
But, CNA/NNU research director Don DeMoro notes the insurers fail to distinguish between “eligible” and “ineligible” claims denied in data they provide the state. And, insurers can choose from a broad list of “ineligibility” criteria offered by the state including disputes over contracts, interest or late payments, benefits “not covered,” and court disputes.
 
DeMoro called on the state to require more transparency in reporting. If further national reform is not forthcoming, he said, individuals and employers alike should “have access to such data to aid them in determining the best value for their money and the best care for all concerned.”
 
“The grave and potentially irreparable nature of the risk to patients subject to unfair claims denials cannot be overstated and certainly justifies the minimal cost to managed care organizations to provide accurate and meaningful claims denial reports,” DeMoro said.

Is HHS pushing bronze plans?

Note: You may want to skip directly to the comment, and only afterwards read the excepts from the HHS release and report, if you wish to review the details.

News Release: Report finds lower insurance premiums, more choices in 2014 for families, businesses under Affordable Care Act

U.S. Department of Health & Human Services
January 28, 2011

Secretary of Health and Human Services Kathleen Sebelius today released a new report showing how much families and businesses can save on health insurance premiums and out-of-pocket costs under the Affordable Care Act in 2014 – each year, a low-income family of four could save up to $14,900 and businesses will benefit from the savings and tax credits in the new law.

The report finds that, compared to what they would have paid without the law:

*  Middle-class families purchasing private insurance in the new State-based Health Insurance Exchanges could save as much as $2,300 per year in 2014.
 
*  Tax credits provided by the Affordable Care Act will lead to even greater savings.  For example, in 2014, a family of four with an income of $33,525 could save as much as $14,900 per year since they will also qualify for tax credits and reduced cost sharing.

http://www.hhs.gov/news/press/2011pres/01/20110128a.html

And…

Report: Health Insurance Premiums: Past High Costs Will Become the Present and Future Without Health Reform

U.S. Department of Health & Human Services
January 28, 2011

This report examines the past, present, and future regarding the likely effects of the law on premiums – along with what might happen without it.

Savings for individuals and families:

The Congressional Budget Office (CBO) produced estimates of the impact of the Affordable Care Act on premiums. For people purchasing nongroup coverage through the Exchanges, it estimated savings of 7 to 10 percent resulting from the increase in the size of the insurance pool as well as the nature of the new enrollees, who, in light of the premium tax credits and the individual responsibility provisions, are likely to be healthier than existing enrollees. An additional 7 to 10 percent savings would result from providing the same set of services to the same group of enrollees – primarily because of the new rules in the market such as eliminating insurance underwriting. CBO also credits some of the savings to increased choices and competition. Together, these savings range from 14 to 20 percent. CBO also assumed that individuals and families would have, on average, coverage that is more comprehensive than what they have now, meaning that the savings would offset by higher premiums due to better coverage. It is important to note that this benefit enhancement is a choice, not a requirement.

Assuming 20 percent premium savings, families purchasing insurance through Exchanges could save as much as $2,300 per year and individuals could save up to $800 in 2014 compared to individual market coverage with the same level of benefits without the law. With premium tax credits, the savings from health reform range from $9,900 for a family of four with income of $33,525 to $3,500 for a family with an income of $78,225 (see Figure and Methodology).

Premium savings are only part of picture for low-income individuals and families. They also may qualify for reduced cost sharing under the Affordable Care Act. For the same families with incomes of $33,525 and $78,225, this could add $5,000 and $1,500 respectively to the premium savings (see Table in Methodology).

METHODOLOGY

The table below uses CBO data to illustrate the savings that could be achieved under health reform in 2014. It uses the CBO single premium data for 2016, deflated to 2014 using its last public estimate of private premium growth (6 percent). Family premiums are calculated by multiplying the single premium by 2.7, the standard ratio of family to single premiums (CBO assumes that the composition of a family policy will change under the new law). It then applies the maximum savings for the individual market of 20 percent, assuming that individuals do not decide to purchase better coverage. The tax credits are calculated by applying the maximum premium payment in the law to the 2011 income (using the latest poverty thresholds) inflated by 1.7 percent (CBO’s August 2010 projection for 2012-2014). Premiums vary by age, region and other factors, so these estimates are illustrative.

The cost sharing estimates were calculated by taking the average out-of-pocket spending for a silver plan in 2016 – $1,900 for an individual and $5,000 for a family according to CBO – and deflating to 2014 assuming 6 percent health cost growth (see above). Assuming a linear relationship between the actuarial value of a silver plan (70 percent) and the average out-of-pocket cost sharing, the reduced cost sharing amounts were calculated using the schedule in the law for individuals and families at different income brackets. This was subtracted from the average out-of-pocket costs for a bronze plan to assess the savings.

The potential premium effects in the text and chart are rounded to the nearest $100. Note: the premium effects shown here differ from earlier estimates from HHS due to the January 20, 2011 update of the poverty guidelines.

(The table from which the numbers in the release and the report are derived can be accessed at the link below. Only the footnotes to the table are reproduced here.)

Source: DHHS
1. CBO 11/30/09 estimate of prior law national average individual market single premium ($5,500), deflated to 2014 assuming 6% annual premium growth and adjusted pro-rata for a plan with an actuarial value of 60%. Family premium is the single premium multiplied by a family factor of 2.7
2. CBO 11/30/09 estimate of average cost sharing under reform ($1,900 / $5,200), deflated to 2014 assuming 6% annual health cost growth, pro-rated for a plan with an actuarial value of 60%.
3. Assumes CBO 11/30/09 gross savings of 20%, not counting the premium cost of buying up benefits.
4. Income inflated to 2014 assuming general inflation of 1.7% per year (CBO, August 2010)

http://www.healthcare.gov/center/reports/premiums01282011a.pdf

Comment: 

By Don McCanne, MD

Today’s selections from the Department of Health & Human Services (HHS) are not so much for the purpose of reading and studying, but rather are presented to provide documentation to support today’s comment. HHS is touting the savings in insurance premiums that will result from having enacted the Patient Protection and Affordable Care Act. The fine print is important in understanding what this touted savings really is.

HHS is comparing family plans that will be offered in the state insurance exchanges with family plans that are currently offered in the individual insurance market. The current plans are terrible, which is the main point that HHS should have made. To keep premiums down to a level that families can barely afford, the existing plans provide very limited benefits, potentially exposing families to very high out-of-pocket expenses.

So that the savings can be calculated on an apples to apples comparison, HHS has selected the most austere plan to be offered in the exchanges – the bronze plan, which has an actuarial value of 60 percent – a plan that’s about as lousy as those on the individual market today. This leaves the family exposed to 40 percent of their health care costs (though admittedly with inadequate income-indexed subsidies, which is important but not covered here further).

The family has the option to buy up to a silver plan,
but then the touted savings goes away. Furthermore, the silver plan is also an under-insurance product since its actuarial value is still only 70 percent, leaving the family responsible for 30 percent of the costs. Although still a lousy plan, as HHS says, “this benefit enhancement is a choice, not a requirement.” What a choice.

Gold and platinum plans with actuarial values of 80 percent and 90 percent will be offered in the exchanges, but very few families will move up to those plans since they must pay the full additional premium. Only the wealthiest families will be able to afford the difference.

The title of HHS’s release says “lower insurance premiums” and “more choices.” But what they bury in their report is that you get lower premiums only if you choose a crappy plan similar to those currently available in the individual market.

We can do far better than that. We can enact an improved Medicare for all. Then you wouldn’t have to worry about unaffordable premiums and out-of-pocket expenses since they would be replaced with equitable taxes which would be affordable for all.