Simple Issues That Were Ignored and Still Are Ignored!


As I was planning my weekend of processing 500 pounds of merlot grapes I thought about the actual planning and whether I could short cut the process due to a very busy schedule including a faculty meeting and additional office work. Having been through the process of making wine from growing the grapes to the end stages of fermenting and aging, one finds out that you can’t shorten the process, a plan founded on experience and data. In fact sometimes the process takes longer due to unintended consequences. One step has to follow the previous if preparation and assessment of each step is planned properly, including back-up procedures if something goes wrong, or just doesn’t reach the needed values, etc.

  • Well, low and behold the process of caring for patients, health care delivery itself can’t be short cut either and needs a well thought out set of plans-the blue print. And now we are seeing it all play out.

On Wednesday, the Census Bureau gave Obamacare/Affordable Care Act(ACA) some good news: the number of people without health insurance dropped to 10.4 percent in 2014, down from 13.3 percent in 2013.

Colorado may be doing even better. When the Affordable Care Act launched two years ago, about 1 in 7 of the state’s residents, or 14 percent, were uninsured, according to the nonprofit, nonpartisan Colorado Health Institute. That figure is now 6.7 percent, according to the organization’s latest data.

Marilyn Kruse, a substitute teacher in the Jefferson County school district west of Denver, is one of those who got insurance after the Affordable Care Act launched.

For seven years before that, she went without insurance because she couldn’t get it through her job. She had been denied coverage because she had pre-existing medical conditions; coverage that she could buy was extremely expensive. All the while, she continued to have health problems: a hip that needed surgery, carpal tunnel, bunions and a slipped disk.

“I had the disk go out and I was confused and scared,” Kruse said.

She was scared that she couldn’t pay to treat or repair her back problems. So she mostly avoided going to the doctor. When she did, she paid thousands of dollars out of pocket.

Then health reform launched. Kruse qualified for tax credits through Colorado’s health insurance exchange, so she could buy a plan that came to $55 a month. “That was a very exciting moment in my life,” Kruse said.

The size of the drop in the number of uninsured people was a surprise, according to Amy Downs, senior director for policy and analysis at the Colorado Health Institute. “I don’t think that anyone was expecting it to really go down this much,” Downs said.

In 2013, nearly 750,000 Coloradans were uninsured. Obamacare cut those numbers in half, to a level that was once considered unreachable, says Downs. (The Census Bureau’s data for Colorado show a less dramatic decrease. However, the Colorado Health Institute report was based on a survey performed in 2015, while the Census survey is from 2014.)

“We see a big growth in our Medicaid population that is much higher than we expected as well,” Downs said.

Under the Affordable Care Act, the decision to expand Medicaid, the health plan for low-income Americans, was left up to the states. Colorado decided to expand. That’s led the state to enroll about 450,000 people in the last two years. One in five Colorado residents is on Medicaid.

But the expansion in health coverage is tempered by rising concerns over cost and the number of people who are underinsured, which means out-of-pocket health costs are still too expensive.

The number of underinsured Medicaid enrollees in Colorado grew by more than 100,000 people since 2013, Downs said. “The increase in the underinsured really stood out for us.”

An unaffordable out-of-pocket cost is defined in the Institute’s survey as more than 10 percent or more of annual income. For those at 200 percent of the federal poverty level, any cost above 5 percent of income is considered unaffordable.

“People on Medicaid have really low incomes, so it doesn’t take very much spending to get them into that underinsured category,” said Downs.

Gwendolyn Funk, a 37-year-old who lives in Dove Creek in the southwest corner of Colorado, considers herself underinsured. “Well, I’m glad that I have insurance, it’s just that I can barely afford my policy and my premiums, along with my children’s,” said Funk.

Funk’s husband, a mechanical engineer, gets insurance through his employer. But it’s too expensive for her and their two kids to get insurance through him. So they pay $500 a month to privately insure Funk and the children.

“We’re going to have to choose between basically either eating or paying for health insurance,” Funk said. “It’s going to be really, really difficult.”

Still, nearly 75 percent of Coloradans give the state’s health care system a thumbs up, saying the current system meets the needs of their family.

The percentage of Americans without health insurance dropped by nearly three percentage points between 2013 and 2014, according the U.S. Census Bureau, from 13.3 to 10.4 percent. Put another way, 8.8 million more people were insured in 2014 than the year before.

The annual study from Census is considered the definitive measure of health insurance, although a change in the way health insurance questions are asked make this year’s report comparable to 2013 but not earlier years.

Census officials, however, point out that a different annual survey that has asked health insurance questions consistently show this to be the biggest drop in the uninsured since at least 2008.

Others say the sizable increase in Americans with insurance — due in large part to the implementation of the federal health law — is unprecedented since the creation of Medicare and Medicaid 50 years ago.

“It’s probably the biggest drop ever,” said Paul Fronstin, director of health research at the Employee Benefit Research Institute, who has been studying the uninsured since 1993.

More importantly, said Diane Rowland, head of the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, “the gains are exactly where the biggest problems were,” meaning the largest increases in coverage were in those groups with traditionally the highest rates of uninsurance — younger, working-age adults and people with low and moderate incomes. (Kaiser Health News is an editorially independent program of the foundation.)

Despite the gains, the Census study found that 33 million people are without insurance.

While the gains in insurance coverage were widespread, they weren’t equal in every category. Not surprisingly, among types of coverage, the biggest increases were in people covered by Medicaid (up 2 percentage points to 62 million people) and people buying their own health plans (up 3.2 percentage points to 14.6 million people). Expanding Medicaid and making private insurance easier to purchase by those without employer coverage were key focuses of the health law.

But the largest single source of health insurance remains employers. That number held steady at around 55 percent.

The uninsured rate dropped for every age, income and ethnic group and in every state, although, again, some gained more than others.

Those at the lower end of the income scale were more likely to gain insurance than those with more resources. The uninsurance rate for households earning less than $25,000 per year dropped 4.3 percentage points. The rate for those with incomes between $25,000 and $50,000 dropped 5 points. The uninsurance rate for those earning more than $100,000 annually dropped too, but by less than a percentage point.

Similarly, the uninsured rate for the white non-Hispanic population (the ethnicity most likely to have insurance) dropped by just over 2 percentage points, while the rates for blacks, Asian-Americans and Hispanics dropped by more than 4 percentage points each.

Among states, Massachusetts (which began requiring most people to have insurance in 2006) had the lowest rate of people without coverage, at 3.3 percent, while Texas continued to lead the nation with the highest uninsured rate — 19.1 percent.

States that expanded Medicaid, however, saw overall gains in insurance — not just Medicaid — that were larger than those that didn’t. For example, people with incomes above poverty but less than four times that (most of whom aren’t eligible for Medicaid) still saw an overall decline in uninsurance of 6.4 percentage points in states that expanded Medicaid, while states that didn’t take that option saw that rate drop by only 4 percentage points.

But remember what the exchange insurance coverage pays physicians I have heard it for years in California with different doctors groups over and over complaining that their net reimbursement from United Healthcare is less than Medicare.  For those why buy insurance plans from exchanges, in many areas United pays somewhere between Medicare and Medicaid rates and that they have published themselves.   In California, complex contracts are used as part of the tools to keep the compensation low.  We keep reading all the time about the expense of doctors and a while back there was a study that came out and it said doctors are not that expensive compared to all the other costs in healthcare.

So if you do find your doctor not in network with United, this could be part of the problem, being paid at rates that are 12% average less than what Medicare pays.  Of course, our current CMS head, Andy Slavitt drove this payment factorization to pay doctors less during his time at United Healthcare, so if confirmed at Head of CMS, that’s what’s there for those who are members, paying doctors even less and dumping more cost to the consumer.  The doctors in this group said they have not had a raise in 6 years with United.  Sometimes doctors are accepting less than Medicare and still get fired from United if the algorithmic formula United uses says no, so they get fired by the algorithms as well.

United Healthcare Extending Narrow Networks in California–More Secret Scoring of Doctors in the US–Telling The Doctors If They Are “Allowed” To Be In Network…

“The Secret Scoring of America’s Physicians” – Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..

The company also has a law firm in New York looking into the reimbursement issues.

Law Firm Investigating UnitedHealthCare Claim Payments in New York Stating Under-Reimbursement By Manipulating Algorithmic Benefit Calculations…

A couple years ago the American Academy of Family Practice doctors took up this issue as well with United paying doctors at rates less than Medicare, so it’s all over the US as an issue.  Don’t be fooled anymore and think that commercial insurers make up for the low payments of Medicare as they don’t always anymore.  There’s enough here in this post to substantiate that.

AAFP Says We’re Not Going To Take It Anymore With Optimization of Provider Networks – Specifically United Healthcare’s Doctor Dumping That Disrupts Continuity of Care.

Is there any reason why doctors are not really happy with United?  Here a couple years ago they put out an article telling the Feds to aggressively manage seniors and they are trying not only manage seniors but everyone else it seems.

United HealthCare Issues Another Study, This One Telling Government To Aggressively Manage Medical Care For Seniors-An Area Where A Large Chunk of Their Revenue Comes From Today, Managing Care

It’s really not fair to the other insurers as well to have this United/Optum monopoly at HHS and CMS that exists today and has been around for years.  CMS now is stuck with a lot of the mentored United models that are not working so well as that’s all they do is numbers when it comes to insurance.

Local doctors who are part of Highland District Hospital’s Professional Services Corporation will no longer be part of the United Healthcare network because they say United’s reimbursement rates have not been increased in six years.

The doctors say the rates have remained unchanged even after three years of negotiations, and that current rates are, on average, 12 percent lower than even Medicare rates as well as the rates paid by most other commercial health insurance carriers.

But it is not just United Health Care, we are seeing this scenario time and time again, in fact in our neighborhood more and more of the local doctors are not taking any more exchange covered patients, no matter which large companies are the covered insurers. So, even though they have insurance, who is going to care for these patients if the designers of the plan haven’t figured out how to pay the caregivers?

I know you all still think that doctors make way too much money. Maybe you all should pay for the malpractice coverage; the computer software and hardware, staffing, etc. that care givers are faced with.

Consider the facts a controversial ACA mandate requires individuals to obtain health insurance or pay a penalty.

But interestingly, the GOP wants to repeal the ACA and there are no real solutions to the repealed ACA.

  • But a recently released report from the Congressional Budget Office estimates repealing the ACA’s individual mandate and its related penalties would “reduce the deficit by about $305 billion” between 2015 and 2025.
  • The agency and the Joint Committee on Taxation (JCT) estimate individual health insurance policy premiums would increase about 20% in all years from 2017 and 2025 under such conditions.

While the savings seem nice, not all of the agencies’ predictions are rosy. CBO and JCT estimate that while eliminating the mandate would save a large sum of money, the number of people without health coverage would increase in 2025 by about 14 million people, with a total of 41 million uninsured that year.

“That increase in the uninsured population would consist of roughly 5 million fewer individuals with coverage under Medicaid or the Children’s Health Insurance Program, 1 million fewer individuals with employment-based coverage, and 8 million fewer individuals with coverage obtained in the individual market (including individual policies purchased through the exchanges or directly from insurers in the non-group market),” the agencies wrote.

We all have to consider that the ACA is not the answer, but to cover all I haven’t heard of a substitute. We need to force our potential Presidential candidates to outline their health care policies.

And remember, there are no short cuts to the care of the patient and to good delivery of health care, whether through the physician’s office, through the hospitals or clinics.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s