Category Archives: Surprise billing

'I owe the American people an apology': A former healthcare executive says he's sorry for devising the biggest argument against Medicare for All and Some Additional Thoughts

As the politicians are getting ready for the Senate impeachment trial, I realize how much time has been wasted on non-health care, non-immigration, non-education improvement, non-environmental issues. Both parties, Democrats and Republicans have wasted and multiple millions of our taxpayer dollars. Pathetic. These are the people that we voter for to do our bidding…improve our lives. Instead they fight and embarrass all of us. Pathetic!

And again, what about Medicare for All? Zeballos-Roig noted that Wendell Potter, a former health insurance executive and now pro-Medicare for All activist, apologized for his role in designing the biggest argument against industry reform in a New York Times op-ed published Tuesday.

He was referring to the idea of choice, or put another way, the freedom of Americans to pick their own health insurance plans and which doctors they want to see.

The activist called it “a PR concoction,” one filling him with “everlasting regret.”

A former executive at a prominent health insurance company had one thing to say recently: I’m sorry.

Wendell Potter, once a vice president for corporate communications at Cigna and now a pro-universal healthcare activist, laid out his apology in the New York Times on Tuesday for crafting one of the biggest arguments used against the creation of a single-payer system in the United States.

He was referring to the idea of choice, or put another way, the freedom of Americans to pick their own health insurance plans and which doctors they want to see.

It’s a common argument the health industry employs to oppose any attempt to change the system. Most recently, its spearheaded a multimillion-dollar effort to throttle proposals for Medicare for All, which would enroll everyone in the US onto a government insurance plan and virtually eliminate the private insurance sector.

“When the candidates discuss health care, you’re bound to hear some of them talk about consumer ‘choice,'” Potter wrote, referring to the Democratic primary field. “If the nation adopts systemic health reform, this idea goes, it would restrict the ability of Americans to choose their plans or doctors, or have a say in their care.

He called it “a good little talking point,” effective at casting any reform proposal expanding the government’s role in healthcare as drastically damaging.

But Potter said that defense was ultimately “a P.R. concoction,” and one that filled him with “everlasting regret.”

“Those of us in the insurance industry constantly hustled to prevent significant reforms because changes threatened to eat into our companies’ enormous profits,” Potter wrote.

Potter resigned his position at Cigna in 2008. And he testified to Congress a year later about the practices of an industry that “flouts regulations” and “makes promises they have no intention of keeping.” He’s since become a leading reform advocate.

Get this, the activist said in the Times op-ed that healthcare executives were well aware their insurance often severely limited the ability of Americans to personally decide how they accessed and received medical care, unless they wanted to pay huge sums of money out of their own pockets.

Do you all believe this?

“But those of us who held senior positions for the big insurers knew that one of the huge vulnerabilities of the system is its lack of choice,” Potter said. “In the current system, Americans cannot, in fact, pick their own doctors, specialists or hospitals — at least, not without incurring huge ‘out of network’ bills.”

The “choice” talking point, Potter wrote, polled well in focus groups that insurers set up to test their messaging against reform plans, leading them to adopt it.

Now he is shocked to see an argument that he had a hand in engineering used among Democrats battling to claim their party’s nomination to face off against President Trump in the 2020 election — and Potter says the insurers likely see it as a huge victory for them.

“What’s different now is that it’s the Democrats parroting the misleading ‘choice’ talking point — and even using it as a weapon against one another,” Potter wrote. “Back in my days working in insurance P.R., this would have stunned me. It’s why I believe my former colleagues are celebrating today.”

One of the biggest divides among Democratic candidates is on health reform.

The progressive wing of the party, led by Sen. Bernie Sanders, largely supports enacting Medicare for All. So does Sen. Elizabeth Warren, though she’s tempered her rhetoric backing it in the last few months after rolling out her own universal healthcare plan and drawing criticism for its hefty $20.5 trillion price tag.

Moderates like former Vice President Joe Biden and South Bend Mayor Pete Buttigieg are pushing to create an optional government insurance plan for Americans instead. They’ve argued that a single-payer system could kick millions of Americans off their private insurance and restrict their ability to manage their care — echoing the line of attack used by the healthcare industry.

Potter had a warning for voters as they head to the polls in this year’s election.

“My advice to voters is that if politicians tell you they oppose reforming the health care system because they want to preserve your ‘choice’ as a consumer, they don’t know what they’re talking about or they’re willfully ignoring the truth,” Potter wrote in the op-ed. “Either way, the insurance industry is delighted. I would know.”

Humana CEO talks M&A, government-controlled health care

More from another healthcare executive. Reporter Chris Larson noted that Louisville-based Humana Inc. — a giant in the health insurance market — expects its long-term success to be based in providing health services to keep its members from needing more care.

Humana CEO Bruce Broussard said as much — and much more — on Monday in two appearances at the J.P. Morgan Healthcare Conference in San Francisco.

Appearing beside Humana Chief Financial Officer Brian Kane, the duo answered a wide range of questions (which you can hear for yourself here). Below are a few takeaways from their remarks.

Humana’s core business is expected to grow despite market leader status

Administering Medicare Advantage, a privately administered version of the federal health plan Medicare, is at the heart of Humana’s (NYSE: HUM) business: it has about 4.1 million members on individual or group Medicare Advantage plans, according to the company’s latest financial disclosure.

One analysis shows that Humana holds about 18 percent of the Medicare Advantage market, the second largest share in the nation.

Presentation moderator Gary Taylor, a managing director and senior equity analyst with J.P. Morgan, noted that continued growth in a market-leading position is not typical and noted that continued growth in the Medicare Advantage business is possible because more seniors are using it rather than traditional Medicare.

Taylor said that about one-third of Medicare enrollees are on Medicare Advantage plans. Broussard said that he expects that portion to grow to one-half in the next seven to 10 years.

“We’re seeing just both a great consumer attraction, but, more importantly, great health outcomes by being able to serve someone more holistically,” Broussard said.

Broussard added that Humana’s growth in Medicare Advantage depends on brand recognition and customer experience. He added he expects that the company can grow along with the popularity of Medicare Advantage in the Midwest and Texas specifically.

Public policy: Americans want a private option

Some Democratic presidential candidates say they would push for expanded health benefits from the government while others — notably Vermont Senator and presidential hopeful Bernie Sanders — want to see private insurance eliminated altogether. Broussard largely downplayed the likelihood that these proposals would become policy.

He referred to polling, the company’s experience and the increased popularity of Medicare Advantage — a privately administered version of a government health plan — as proof that people want private options in health care.

Humana’s M&A plans will focus on clinical capabilities

Broussard said clinical capabilities were key to the company’s success and later added that its merger and acquisition activity would largely focus on that.

“What we see long term is the ability to compete in this marketplace will be really determined on your clinical capabilities — helping members stay out of the health care system as well as what we’ve done in past in managing costs in the traditional managed care way,” Broussard said.

Broussard added later in the presentation: “As we think about growth, we really think about how do we build the health care services side more. We’ll still buy plans especially on the Medicaid side and the markets that we want to be in. But for the most part, I think our capital deployment is expanding the capabilities we have.”

He added that there are only a few options for additional blockbuster mergers in the health care industry given the current regulatory environment.

Humana was the subject of such a merger a few years ago with Hartford, Connecticut-based Aetna Inc. But that deal fell apart and Aetna has since merged with Woonsocket, Rhode Island-based CVS Health Inc.

Humana was party to a $4.1 billion acquisition that took Louisville-based Kindred Healthcare private and separated Kindred At Home into a standalone entity.

How an insured pro athlete ended up with $250,000 in medical debt

With all the concern regarding patients without health care insurance that there are people with insurance who due to the complexities of the system still end up with huge bills sometimes ending in bankruptcies. In the U.S., going bankrupt because of medical bills and debt is something that doesn’t just happen to the unlucky uninsured, but also to people with insurance.

Though health plans have an “out of pocket max” – the most you’d be required to pay for medical services in a given year – that’s no guarantee that number will ensure a safety net.

This is what pro cyclist Phil Gaimon discovered after a bad crash in Pennsylvania last June that left him with his collarbone, scapula, and right ribs broken. The bills totaled $250,000.

“I have good insurance,” Gaimon told Yahoo Finance. “I pay a lot of money for it. I just haven’t gotten good explanations for any of this.”

Gaimon pays $500 a month for a plan with a $10,000 deductible, and is fighting the bills.

This type of medical debt isn’t uncommon. The Kaiser Family Foundation, a healthcare think tank, has reported that insurance can be incomplete and that the complexity of the system often leaves people seeking treatment in financial hardship. In a survey KFF found that 11% of consumers with medical bill problems have declared bankruptcy, and cited the medical bills as at least a partial contributor. Another report found that medical problems contributed to 66.5% of all bankruptcies. (Currently, there’s some legislation addressing surprise billing issues.) 

Gaimon was taken by ambulance to the nearest hospital after his crash. Unfortunately, it turned out to be an out-of-network hospital. Gaimon told Yahoo Finance that he thought it would be okay, because the emergency nature could be seen as an extenuating circumstance. His insurer, Health Net, has an appeals process for situations like that.

Gaimon figured the no-other-option aspect of the situation would solve the problems, and believed it enough to post on Instagram soon after that people should donate to No Kid Hungry, a children’s food insecurity charity, rather than a GoFundMe for his bills.

“I said, ‘Hey, I crashed, what would you donate to my GoFundMe if i didn’t have health insurance? Take that money and give it to this instead,’” said Gaimon. “We raised around $40,000 in 48 hours.”

The $103,000 raised in the next few months would have taken a big chunk out of his medical bills, but Gaimon has no regrets. “Someone out there needs more help than I do,” he said.

Medical bills are fun!

It’s hard to comparison shop when you’re in physical pain

Things may have been easier if it would have been possible for Gaimon to steer the ambulance towards an in-network hospital. But an ambulance isn’t a taxi — it’s a vehicle designed to bring a patient to health care providers in the least amount of time possible.

Also consider that Gaimon, as he put it, was in “various states of consciousness” following his accident — hardly in a position to check which hospitals are in his insurer’s network.

Gaimon may be able to win the appeals process with his insurer for the out-of-network hospital. But that’s just the beginning of his insurance woes.

The cyclist’s scapula break was complex enough to require a special surgeon, and Gaimon said the hospital was unable to find someone capable. 

“I was laying in the hospital for three days hitting the morphine,” Gaimon said. Multiple times a potential surgeon would come to examine him only to say that they weren’t up to the task. 

After multiple cycles of fasting before a surgery only to be told that the surgeons couldn’t operate, Gaimon took matters into his own hands. Eventually he found a surgeon in New York to do it, and even though it was out-of-network as well, he figured the fact that there was seemingly no other alternative would mean his insurer would cover the surgery. 

So the track race didn’t go very well. Broken scapula, collarbone, 5 ribs, and partially collapsed lung.  What if I told you that I don’t have health insurance? Would you donate do help me out? How much?

Okay well I do have health insurance and I’m fundamentally alright, so I ask you to take that money and give it to @ChefsCycle @nokidhungry who need it more than I do. I’m in a lot of pain and this is all I can think to cheer me up. Link in profile and updates as I have them. Xo

Six months later, Gaimon finds out that it did not, and is fighting the charges. He’s hired a lawyer to help, as has had mixed results with the system so far. 

“No one talks prices until it’s over — that’s the other horrible flaw,” he said. 

Gaimon said that he’s numb to things at this point, though he doesn’t know what will happen.

“Ultimately I’m going to have to negotiate with that hospital, or the health insurance will choose to cover,” said Gaimon. “Or they’ll have to sue me and I’ll go bankrupt — the traditional way you deal with medical stuff.” 

Gaimon’s sarcasm aside, sky-high health care costs are a central issue in the current presidential election and a frequent talking point for Democratic candidates. In this week’s Democratic debate, Sen. Bernie Sanders highlighted the issue. “You’ve got 500,000 people going bankrupt because they cannot pay their medical bills,” Sanders said. “We’re spending twice as much per capita on health care as do the people of any other country.”

The whole ordeal has shown Gaimon how fragile the healthcare system really is. 

“The whole idea that you could be in a car accident and you wake up in a hospital and owe $100,000 — and that could happen to anyone — that’s a ridiculously scary thing,” he said. “I was making no decisions, I was on drugs, and in fetal-position-level pain. Every decision was made to live. And then you emerge and you’re financially ruined.”

Medicare for All? A Public Option? Health Care Terms, Explained

Now, a review of some of the terms that we keep discussing. As I complete a chapter in my new book, I thought that it would worth taking the time to review some of the terms. Yahoo Finance’s Senior writer, Ethan Wolff-Mann reported that if the last few Democratic presidential debates are any guide, tonight’s will likely delve into health care proposals. Do voters know what we’re talking about when we talk about various plans and concepts, including “Medicare for All?” Or any of the other health policy terms that get thrown around?

Pretty much no.

According to one poll from the Kaiser Family Foundation, 87% of Democrats support “Medicare for All,” while 64% of Democrats support “single-payer health care.” Here’s the catch — those two phrases describe almost the same thing. The language in this debate is murky, confusing and hugely consequential. So, we’re laying out some key terms to help you keep up.

Single-payer

This is a kind of health care system where the government provides insurance to everyone. Think about it as if you’re a doctor: a patient comes in, and you treat them. Who’s paying you for that care? Under our current system, it could be a variety of payers: state Medicaid programs, Medicare, or a private insurance company like Aetna or Cigna or Blue Cross and Blue Shield — each with different rates and different services that they cover. Instead, under the single-payer model, there’s just one, single payer: the government.

Medicare for All

If single-payer is fruit, Medicare for All is a banana. In other words, single-payer is a category of coverage, and Medicare for All is a specific proposal, originally written by presidential candidate Sen. Bernie Sanders (as he often reminds us). It envisions the creation of a national health insurance program, with coverage provided to everyone, based on the idea that access to health care is a human right. Private health insurance would mostly go away, and there would be no premiums or cost-sharing for patients.

Important note: it would not actually just expand Medicare as it exists now for all people (as you might guess from the name). Medicare doesn’t cover a whole lot of things that this proposed program would cover, like hearing and vision and dental and long-term care.

Public option

The idea of a “public option” was floated back in 2009 when the Affordable Care Act was being debated. The idea is that along with the private health insurance plans that you might have access to through your employer or through the individual insurance exchanges, there would be an option to buy into a government-run insurance program, like Medicare. Private insurance would still exist, but people could choose to get a government insurance plan instead.

There are many kinds of public option proposals, and different presidential candidates have their own ideas on how it would work, whether it’s lowering the age for Medicare access or creating a new program that’s not Medicare or Medicaid that people could buy into, among others. The idea is that the government might be able to offer a more affordable option for people, which could push down prices in the private insurance world.

Pete Buttigieg’s plan — “Medicare for All Who Want It” — is his version of a public option. And Elizabeth Warren announced November 15 that she’d start with a public option plan before trying to push the country toward Medicare for All.

“Government-run” health care

Many opponents of Medicare for All and other health proposals use the term “government-run” as a dig against them, including President Trump. (Sometimes the term “socialized medicine” is used as well.) In the U.K. and some other places, the government doesn’t just pay people’s health care bills, it also owns hospitals and employs doctors and other providers — that’s a government-run health care system. The single-payer concept being discussed in this country’s presidential campaign would not operate like that — the industry would still be mostly private, but the government would pay the bills. How the government would generate the money to pay those bills is subject to debate.)

Universal coverage

This isn’t a plan, it’s a goal that everyone has health insurance — that health insurance coverage is universal. The Affordable Care Act made a system for states to expand Medicaid and created the individual health insurance exchanges, , both of which significantly cut down on the number of uninsured people, but currently 27 million Americans do not have health insurance, and the rate of people who lack insurance is rising. Most Democratic presidential candidates would like to achieve universal coverage — the debate is about the best approach to get there.

Medicare for All Would Save US Money, New Study Says

Reporter Yuval Rosenberg, The Fiscal Times noted that a Medicare for All system would likely lower health care costs and save the United States money, both in its first year and over time, according to a review of single-payer analyses published this week in the online journal PLOS Medicine. You have to read on to understand the flimsy data and weak argument to try to convince us all to adopt the Medicare for All program, especially those of us who really know the reality of living with a Medicare type of healthcare program and the reality of restrictions in needed care for the patients.

The authors reviewed 18 economic analyses of the cost of 22 national and state-level single-payer proposals over the last 30 years. They found that 19 of the 22 models predicted net savings in the first year and 20 of 22 forecast cost reductions over several years, with the largest of savings simplified billing and negotiated drug prices.

“There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents,” the study says. It notes that actual costs would depend on the specifics features and implementation of any plan.

The peer-reviewed study’s lead author, Christopher Cai, a third-year medical student at the University of California, San Francisco, is an executive board member of Students for a National Health Program, a group that supports a single-payer system.

Questions about methodology: “This might be the worst ‘academic’ study I’ve ever read,” tweeted Marc Goldwein, head of policy at the Committee for a Responsible Federal Budget. “It’s a glorified lit review of 22 studies – excluding 6 of the most important on the topic and including 11 that are redundant, non-matches, or from the early 90s.” The results would look quite different if the authors had made different choices about what analyses to include in their review.

What other studies have found: Other recent analyses have been far less conclusive about how health care spending might change under a single-payer system. The nonpartisan Congressional Budget Office said last year that total national health care spending under Medicare for All “might be higher or lower than under the current system depending on the key features of the new system, such as the services covered, the provider payment rates, and patient cost-sharing requirements.”

An October analysis by the Urban Institute and the Commonwealth Fund, meanwhile, found that a robust, comprehensive single-payer system would increase national health spending by about $720 billion in its first year, while federal spending on health care would rise by $34 trillion over 10 years. But a less generous single-payer plan would reduce national health spending by about $210 billion in its first year. Remember the costs that Elizabeth Warren spouted?? $52 trillion over a decade! Can we all afford this?

The Conversation We Refuse to Have About War and Our Veterans, Hospital Billing and More on the History of Medicare.

Screen Shot 2019-05-26 at 11.34.05 PMMemorial Day and the latest redeployment of soldiers and a carrier group to the Middle East is a perfect time to realize that Veterans bear the burden of war long after they leave the battlefield. It’s time for America to acknowledge it.

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

“You can shoot her…” the First Sergeant tells me. “Technically.”

Benjamin Sledge wrote reflecting, we’re standing on a rooftop watching black smoke pillars rise from a section of the city where two of my teammates are taking machine gun fire. Below, the small cluster of homes we’ve taken over is taking sporadic fire as well. He hands me his rifle with a high powered scope and says, “See for yourself.”

It’s the six-year-old girl who gives me flowers.

We call her the Flower Girl. She hangs around our combat outpost because we give her candy and hugs. She gives us flowers in return. What everyone else at the outpost knew (except for me, until that day) was that she also carried weapons for insurgents. Sometimes, in the midst of a firefight, she would carry ammunition across the street to unknown assailants.

According to the rules of engagement, we could shoot her. No one ever did. Not even when the First Sergeant morbidly reassured them on a rooftop in the middle of Iraq.

Other soldiers didn’t end up as lucky.

Sometimes they would find themselves paired off against a woman or teenager intent on killing them. So they’d pull the trigger. One of the sniper teams I worked with recounted an evening where he laid up a pile of people trying to plant an IED. It was a “turkey shoot,” he told me laughing. But then he got quiet and said, “Eventually they sent out a woman and this dumb kid.” I didn’t need to ask what happened. His voice said it all.

I often wonder what would have happened if the Flower Girl pointed a rifle at me, but I’m afraid I already know. The thought didn’t matter anyway. There was enough baggage from tours in Afghanistan and Iraq that coming home was full of uncertainty, anger, and confusion — and not, as I had been led to believe, warmth and safety.

“People only want to hear the Band of Brothers stories. The ones with guts and gusto! Not the one where you jam a gun in an old woman’s face or shoot a kid.” I pause, then add, “Look around the room for a second…”

Andy surveys the restaurant we’re in for a moment while I lean in with a sardonic half-smile.

“How many people can even relate to what we’ve been through? What would they rather hear about? How Starbucks is giving away free lattes and puppies this week? Or how a soldier feels guilty because he pulled a trigger, lost a friend, or did morally questionable things in war? Hell, I want to hear about the latte giveaway… especially if it’s pumpkin spice.”

This eases the tension and he smiles.

Andy and I feel like we don’t fit in. We met a few years ago at the church where he works, and where I volunteer. Of the thousands of people in the congregation, we are a handful of veterans. The veterans I meet are few and far between, and we typically end up running in the same circles.

How do you talk about morally reprehensible things that have left a bruise on your soul?

Years ago, Andy fought in the siege of Fallujah. We never readjusted to normal life after deployment. Instead, we found ourselves angry, depressed, violent and drinking a lot. We couldn’t talk to people about war or its cost because, well, how do you talk about morally reprehensible things that leave a bruise on your soul?

The guilt and moral tension many veterans feel is not necessarily post-traumatic stress disorder, but a moral injury — the emotional shame and psychological damage soldiers incur when we have to do things that violate our sense of right and wrong. Shooting a woman or child. Killing another human. Watching a friend die. Laughing about situations that would normally disgust us.

Because so few in America have served, those who have can no longer relate to their peers, friends, and family. We fear being viewed as monsters or lauded as heroes when we feel the things we’ve done were morally ambiguous or wrong.

The U.S. is currently engaged in the longest running war in the history of the United States. We are entering our 15th year in Afghanistan, and we still station troops in some Iraqi outposts. In World War II, 11.5% of U.S. citizens served in four years. In Vietnam, 4.3% served in 12 years. Since 2001, only 0.86% of our population has served in the Global War on Terror. Yet, during World War II, 10 million men were drafted, and over 2 million men were conscripted during Vietnam. Despite the length of the Iraq and Afghan Wars, there has been no draft, whereas, in times past, shorter wars cost us millions of young men. Instead, less than 1% of the population has borne this burden, with repeated tours continually deteriorating our troops’ mental health.

Screen Shot 2019-05-25 at 8.13.38 PM

The gap between citizens and soldiers is growing ever wider. During WWII, the entire nation’s focus was on purchasing war bonds and defeating the Nazis. Movie previews and radio shows gave updates on the war effort. Today’s citizens, however, are quickly amused by the latest Kardashian scandal on TV, which gives no reminder of the men and women dying overseas. Because people are more concerned about enjoying their freedoms and going about their day to day lives, veterans can feel like outcasts. As though nothing we did matter to a country that asked us to go.

This is part of the problem with a soldier’s alienation. People quickly point out that we weren’t forced to join the military and fight in a war. We could have stayed home. The counterpoint is that, because the U.S. has now transitioned to an all-volunteer force, those opposed to war should be thanking their lucky stars that volunteers bear the burden of combat.

Additionally, regardless of whether you’re Republican, Democrat, Libertarian, Communist, Liberal, Conservative, Conscientious Objector, or Pacifist, we all sent the soldier overseas. Because we live in a democracy, we vote to put men and women in charge of governing our affairs, and those elected representatives send troops overseas. We may have voted for someone else, but it does not change the fact that we’ve put ourselves under the governance of the United States. When you live in a country, you submit yourself to their governing body and laws — even if you don’t vote.

The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place.

By shirking responsibility, civilians only alienate our soldiers more. The moral quagmire we face on the battlefield continues to dump shame and guilt onto our shoulders while they enjoy the benefits of passing the buck and asking, “Whose fault is it, really?”

On March 3, 1986, 11 years after the end of the Vietnam War, Metallica released their critically acclaimed album Master of Puppets. On the album, a song entitled “Disposable Heroes” tells the story of a young man used as cannon fodder in the midst of war and the terror that enveloped him on the battlefield. Three years later, Metallica released “One,” a song about a soldier who lost all his limbs and waits helplessly for death. The song won a Grammy for Best Metal Performance.

In an odd twist, both songs are amazingly popular among members of the United States military. During my time at the John F. Kennedy Special Warfare Center, we had an entire platoon that could practically sing every last lyric to “One.” In Afghanistan and Iraq, these songs were on playlists made to get soldiers amped before missions. We sang songs about dying on behalf of the people or coming home a vegetable. As crazy as that sounds, we sang those songs because they felt true. And they felt true because of the conversation we refuse to have as a country.

As Amy Amidon, a Navy psychologist stated in an interview regarding moral injury:

Civilians are lucky that we still have a sense of naiveté about what the world is like. The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.

Most of the time, like the conversation Andy and I had, people only want to hear the heroics. They don’t want to know what the war is costing our sons and daughters in regard to mental health, and this only makes the gap wider. In order for our soldiers to heal, society needs to own up to its part in sending us to war. The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place. Citing a 2004 study, David Wood explains that the “grief over losing a combat buddy was comparable, more than 30 years later, to that of a bereaved spouse whose partner had died in the previous six months.” The soul wounds we experience are much greater. Society needs to come alongside us rather than pointing us to the VA.

Historically, many cultures performed purification rites for soldiers returning home from war. These rites purified a broad spectrum of warriors, from the Roman Centurion to the Navajo to the Medieval Knight. Perhaps most fascinating is that soldiers returning home from the Crusades were instructed to observe a period of purification that involved the Christian church and their community. Though the church had sanctioned the Crusades, they viewed taking another life as morally wrong and damaging to their knights’ souls.

No one in their right mind wants war. We want peace. And no one wants it more than the soldier.

Today, churches typically put veterans on stage to praise our heroics or speak of a great battle we’ve overcome while drawing spiritual parallels for their congregation. What they don’t do is talk about the moral weight we bear on their behalf.

Dr. Jonathan Shay, the clinical psychologist who coined the term moral injury, argues that in order for the soldier and society to find healing, we must come together and bear the moral responsibility of what soldiers have done in our name.

Whether you agree or disagree with the war, you must remember that these are our fellow brothers and sisters, sons and daughters, flesh and blood. As veterans, we are desperate to reconnect with a world we feel no longer understands us. As a country, we must try and find common ground. We’re not asking you to agree with our actions, but to help us bear the burden of carrying them on behalf of the country you live in. A staggering 22 veterans take their lives every day, and I can guarantee part of that is because of the citizen/soldier divide.

But what if it didn’t have to be this way? What if we could help our men and women in uniform bear the weight of this burden we carry? We should rethink exactly what war costs us and what we’ve asked of those who’ve fought on our behalf. In the end, no one in their right mind wants war. We want peace. And no one wants it more than the soldier. As General Douglas MacArthur eloquently put it:

“The soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war.”

And what do we offer our Veterans for their healthcare when they come home? A truly horrid attempt at a government-run healthcare system, which now is pushing to get our Vets to private healthcare programs!!

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

Our friend Joyce Frieden wrote that responses are generally positive so far regarding draft bipartisan legislation on surprise billing and high drug prices released Thursday by the Senate Health, Education, Labor, and Pensions (HELP) Committee.

“We commend this bipartisan effort to address several of the key factors associated with rising health care costs,” Richard Kovacs, MD, president of the American College of Cardiology, said in a statement.

“We agree with and support many of the principles outlined by the HELP Committee,” Matt Eyles, president, and CEO of America’s Health Insurance Plans, a trade group for health insurers, said in a statement. “We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”

The HELP Committee draft bill, known as the Lower Health Care Costs Act, would:

  •  Require that patients pay only in-network charges when they receive emergency treatment at out-of-network facilities, and when they are treated at an in-network facility by an out-of-network provider that they did not have a say in choosing/
  • Ban pharmacy benefit managers (PBMs) from “spread pricing” — charging employers, health insurance plans, and patients more for a drug than the PBM paid to acquire the drug.
  • Require insurance companies to keep provider directories up to date so patients can easily know if a provider is in-network.
  • Require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days, to prevent unexpected bills many months aftercare.
  • Ensure that makers of branded drugs, including insulin products, are not gaming the system to prevent generics or biosimilars from coming to market
  • Eliminate a loophole that allows the first company to submit a generic drug in a particular class to enjoy a monopoly
  • Give patients full electronic access to their own health claims information.

Although the patient will only need to pay in-network charges when receiving service from an out-of-network provider, that in-network amount won’t pay for the entire out-of-network bill, so lawmakers still must decide how to deal with the rest of the out-of-network charge. The committee says it’s considering several options, including having insurance companies pay the out-of-network providers the median contracted rate for the same services provided in that geographic area, and, for bills over $750, allowing the insurer or the provider to initiate an independent dispute resolution process. The insurer and provider would each submit a best final offer and the arbiter would make a final, binding decision on the price to be paid.

The bill’s provisions “are common-sense steps we can take, and every single one of them has the objective of reducing the health care costs that you pay for out of your own pocket,” committee chairman Lamar Alexander (R-Tenn.) said in a statement. “We hope to move it through the health committee in June, put it on the Senate floor in July and make it law.” The bill is co-sponsored by Sen. Patty Murray (D-Wash.), the HELP Committee’s ranking member.

Over on the House side, legislators also released a bipartisan bill Thursday on surprise billing. This bill, known as the Protect People From Surprise Medical Bills Act, mirrors the Senate bill in prohibiting balance billing to patients receiving emergency care out of network or anticipated care at in-network facilities that use out-of-network providers without the patient’s knowledge or consent.

The patient would pay in-network rates in those situations, and then the health plan would have 30 days to pay the provider at a “commercially reasonable rate.” If either party is dissatisfied with that rate, the plan and doctor would settle on a payment amount; if that didn’t work, the parties could go to arbitration.

This legislation “will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers,” Rep. Raul Ruiz, MD (D-Calif.), the bill’s main sponsor, said in a statement. “As an emergency doctor, patients come first and must be protected.”

Co-sponsors of the bill include representatives Phil Roe, MD (R-Tenn.), Donna Shalala (D-Fla.), Joseph Morelle (D-N.Y.), Van Taylor (R-Texas), Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), and Brad Wenstrup (R-Ohio). The group expects to introduce the final legislation in the next few weeks.

The American Society of Anesthesiology (ASA) praised the House bill. “The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills,” ASA president Linda Mason, MD, said in a statement. “The proposal doesn’t pick winners or losers but instead places the dispute where it should be — between the health care provider and the insurance company.”

The American Medical Association (AMA) also liked the bill. “The outline released today represents a common-sense approach that protects patients from out-of-network bills that their insurance companies won’t pay while providing for a fair process to resolve disputes between physicians and hospitals and insurers,” AMA president Patrice Harris, MD, said in a statement.

Now, back to Medicare and the history of healthcare reform. Next, there was a convening of a National Health Conference, which had earlier approved a report of its Technical Committee on Medical Care, urging a huge extension of federal control over health matters. Sound familiar? Here we are in 2019 urging more control of the federal government over health care again in the form of a government-run health care system as either Obamacare or Medicare for All. The conference in 1938 opened with a statement by President Roosevelt describing the ultimate responsibility of the government for the health of its citizens.

The “technical committee” advised the Conference recommended that the federal government enact legislation in several areas:

  1. An expansion of the public health and maternal and child health programs including the original Social Security Act.
  2. A system of grants to the various states for direct medical care programs.
  3. Federal grants for hospital construction.
  4. A disability insurance program that would insure against loss of wages during illness.
  5. Grants to the states for the purpose of financing compulsory statewide health insurance programs.

The total costs of the program were about $850 million tax-funded and now compare this to the cost of Medicare for All at about $34 trillion. We should have adopted Medicare for All then. We would have saved a boatload of money.

It was interesting to learn that in order to placate the majority of medical practitioners the Committee urged the adoption of these programs on the state level. The reason why physicians opposed a program on the national level was the fear of becoming government salaried employees with not much to say in the administration of the program.

As predicted in 1943 when Senator Robert Wagner of New York, together with Senator James Murray of Montana and Representative John Dingle of Michigan, introduced a bill, which called for compulsory national health insurance/ mandatory health insurance as well as a federal system of unemployment insurance, broader coverage and extended benefits for old-age insurance, temporary and permanent disability payments underwritten by the federal government, unemployment benefits for veterans attempting to reenter civilian life, a federal employment service, and a restructuring of grants-in-aid to the states for public assistance.

Roosevelt wasn’t against the bill but he wasn’t prepared to endorse a bill quite so sweeping and so the bill dies in committee. But interestingly Roosevelt wanted to save the issue of national health care for the next presidential campaign in 1944. During the campaign he then called for an “Economic Bill of Rights,” which would include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment” and in his budget message of January 1945 he announced his intention of extending social security to include medical care.

However, Roosevelt died in April 1945 and then Harry Truman took over the presidency committed to most of the same domestic policies as Roosevelt. But then came politics and party and the attempts to enact a health insurance bill during the Truman era came to a definite end with the election of 1950 where a number of the proponents of the mandatory national health insurance were defeated as well as a vigorous and costly campaign by the American Medical Association which was against compulsory health insurance associating the plan in the mind of the public with notions of socialism. Sound familiar?

More next week!

Let us all thank our veterans, our heroes, our real Avengers for all that they have done to assure us all of living in such a great free country. Happy Memorial Day!!

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Health Insurance Inflation Hits Highest Point in Five Years and More on Medicare; and What is this about Abortion and SATs?

57358059_1998437466952569_3700281945192660992_nFirst of all, I must yell and scream at the idiots in the States, you know who you are, that have or are in the process of passing the most restrictive abortion bills. This is especially Alabama where Governor Kay Ivey signed the strictest anti-abortion law. Legislation to restrict abortion rights has been introduced in 16 states this year. The Alabama Senate approved a measure on last week that would outlaw almost all abortions in the state, setting up a direct challenge to Roe v. Wade, the case that recognized a woman’s constitutional right to end a pregnancy. The legislation bans abortions at every stage of pregnancy and criminalizes the procedure for doctors, who could be charged with felonies and face up to 99 years in prison. It includes an exception for cases when the mother’s life is at serious risk, but not for cases of rape or incest — a subject of fierce debate among lawmakers in recent days. The House approved the measure — the most far-reaching effort in the nation this year to curb abortion rights and was just signed by the Governor.

What the heck are you thinking, not even for rape or incest? You are forgetting the women who bare the brunt of your idiot decisions. Do you think that the Supreme Court will overturn Roe versus Wade, passed in 1973? Get real and attend to the real multiple crises out there!

And diversity scores on the SAT exams??? Again, what are you all thinking? I know to correct the “crises of rich parents who got their “unfortunate” children into the best of colleges. Next, the strategy to get our children into good colleges will be to take courses to improve their test-taking abilities, but now they will have to figure out how to improve their adversity scores. Mom and Dad, we need to move into the ghettos of Scarsdale, get on food stamps, get fired from your high paying jobs and become homeless. I know this all sounds crazy, but that is where we are.

Shelby Livingston wrote that the health insurance inflation rate hit a five-year peak in April, possibly because managed care is rising.

The Consumer Price Index for health insurance in April spiked 10.7% over the previous 12 months—the largest increase since at least April 2014, according to a Modern Healthcare analysis of the U.S. Bureau of Labor Statistics’ unadjusted monthly Consumer Price Index data.

In contrast, the other categories that make up the medical care services index—professional services and hospital and related services—rose 0.4% and 1.4% in April, respectively. The CPI for medical care services in April rose 2.3%, while overall inflation increased 2% year over year.

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Because of the way the BLS calculates the health insurance index, the change year over year does not reflect premiums paid by customers, but “retained earnings” after paying out claims. These earnings are used to cover administrative costs or are kept as profit.

The BLS redistributes the benefits paid out a portion of the health insurance index to other non-insurance medical care categories, such as physician services.

The likely reason health insurance inflation is rising is because of growth in managed care, including Medicare Advantage, Medicaid managed care and commercial insurance, according to Paul Hughes-Cromwick, an economist at Altarum. He noted that added administrative costs increase insurance price growth.

Hughes-Cromwick said the increase in the health insurance index could also be driven by the fact that insurers’ medical loss ratios may be decreasing as high premiums, particular in the individual health insurance exchanges, exceeded anticipated claims.

The medical loss ratio reflects the percentage of every premium dollar spent on medical claims and quality improvement. Insurers must pay at least 80% of premiums on those things and if they don’t, they must issue rebates to plan members, as part of the Affordable Care Act.

In response to rising inflation, a spokeswoman for America’s Health Insurance Plans, the industry’s biggest lobbying group, commented that “consumers deserve the lowest possible total costs for their coverage and care.” She pointed out the medical loss ratio requirements and said health insurers spend 98 cents of every premium dollar on medical care, operating costs that include care management, and preventing fraud, waste, and abuse.

Affordable Care Act exchange insurers hiked premiums higher than necessary in 2018 and now expect to pay out $800 million in rebates to individual market customers this year because they did not meet the medical loss ratio threshold, according to a Kaiser Family Foundation analysis published this month. Because medical loss ratios are declining, health insurers in the individual, small group and large group markets expect to issue $1.4 billion in rebates based on their 2018 performance, the analysis stated.

Still, health insurance profits have been on the rise. The eight largest publicly traded insurers posted net income of $9.3 billion in the first quarter of 2019, an increase of 29.9%. They made a combined $21.9 billion in profits over the course of 2018.

Medicaid waiver loophole sparks transparency concerns

Robert King noted that the CMS is doing a poor job in ensuring the public knows about major changes to Medicaid, including the installation of work requirements, a federal watchdog said Friday.

The Government Accountability Office’s report found that the CMS has limited transparency for amendments to existing Section 1115 waivers. That has allowed some states to score approval for their work requirements while skirting some rules, such as projecting how the changes will impact Medicaid enrollment.

The government watchdog noted that two of the four states it studied did not seek public comment on changes that could significantly impact Medicaid beneficiaries.

The transparency requirements for an amendment are more relaxed than a new waiver application, the GAO said. Arkansas and New Hampshire both added work requirements to their Medicaid programs through amendments to their existing Section 1115 waivers.

Currently, new waivers or extension requests must include whether the state thinks that enrollment will decrease and any spending changes. While amendments must address the impact on beneficiaries and explain the changes, there are fewer requirements for what information must be disseminated to the public.

The GAO also found that the CMS had inconsistent transparency requirements for amendments.

For example, the CMS determined Massachusetts’ amendment to waive non-emergency medical transportation was incomplete because the application didn’t include a revised design plan. However, the CMS-approved Arkansas’ work requirement amendment even though it did not include a revised design plan.

The GAO recommended that the CMS develop standard transparency requirements for new waivers, extension requests, and significant Section 1115 amendments.

In response, HHS said it has already implemented policies to improve transparency. GAO said those changes “do not apply to amendments.”

The CMS also lacks policies for ensuring that major changes to a pending application are transparent.

The report comes as the Trump administration is appealing a federal judge’s decision to strike down Medicaid work requirement programs in Kentucky and Arkansas.

Seven other states have received CMS approval for work requirements. Those states are Arizona, Indiana, Michigan, New Hampshire, Ohio, Utah, and Wisconsin. Another six states—Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia—have applications pending federal approval.

Industry enters new battle phase over surprise billing

Susannah Luthi reported that the knives are out over legislation to end surprise medical bills and specifics haven’t even been unveiled yet. But will this solve the problems of the healthcare crisis?

The industry is pushing back hard against a particular principle laid out by President Donald Trump last week.

The administration wants all out-of-network charges from a doctor at an in-network hospital to be wrapped into a single bill from the hospital.

How this provision will technically play out in policy is yet to be seen, as the Senate health committee plans to release its legislative package on surprise medical bills this summer.

But the administration’s position has roiled hospital groups and specialty physicians like emergency doctors, radiologists, and anesthesiologists, who don’t always share the same insurance network as hospitals and have higher than average charges.

“Untested proposals such as bundling payments would create significant disruption to provider networks and contract without benefiting patients,” American Hospital Association CEO Rick Pollack said in a statement shortly after Trump made his remarks. He reiterated the AHA’s position that all Congress needs to do is enact a ban on balance billing and leave the rest to the industry to figure out.

Specialty physicians argue that a single bill will complicate all the billing processes on the back-end with hospitals and insurers.

Dr. Sherif Zaafran, a Texas anesthesiologist, said he doesn’t see room within the White House framework for a policy he could support. He sees it as undercutting specialty physicians’ independence from hospitals. “As a patient, I think a single hospital bill on the surface sounds really good, but in the reality of how most of us practice it’s probably not very practical,” Zaafran said. “A single bill would imply you’re marrying the system for how a physician gets paid with other components that bill completely separately.”

He expects a resulting policy would end up cutting pay for both hospitals and ancillary physicians—hospitals taking a hit as they try to collect the fee and reimburse the physician, and physicians taking a hit if hospitals need to negotiate with insurers on their behalf.

“There are downstream effects that folks haven’t thought through,” Zaafran said.

But the administration’s stance shows how thinking around policy has morphed during months of scrutiny of the issue. And analysts have been documenting the trajectory of high ancillary physician charges in part to lay out the argument for payment bundles.

Discussions started last fall with an initial legislative push from a bipartisan group led by Sens. Bill Cassidy (R-La.) and Michael Bennet (D-Colo.). Cassidy and his co-sponsors introduced a draft proposal to cap out-of-network charges at a regional average. Not long after, Sen. Maggie Hassan (D-N.H.) pitched arbitration to settle disputes between insurers and providers.

As the months passed, the debate transitioned into a look at the underlying contracts between hospitals and insurers—even as policy analysts note that the problem of surprise medical bills is limited to a small number of hospitals.

Experts and economists from think tanks like the Brookings Institution, American Enterprise Institute, and the Urban Institute have weighed in, aided by data from states that have tried to curb the practice in the individual insurance markets that fall under their regulating power.

Several have warned that if lawmakers don’t handle the policy carefully, they could end up inflating overall costs, leading to higher premiums and expenses in an already costly system.

Joyce Frieden pointed out the solutions proposed by the President and hopefully most of the GOP.  President Trump announced an initiative Thursday aimed at ending the problem of surprise medical billing, in which patients undergoing procedures at in-network hospitals receive unexpectedly high bills because one or more of their clinicians was out of network.

Trump called surprise billing as I just outlined, “one of the biggest concerns Americans have about healthcare” and added, “The Republican Party is very much becoming the party of healthcare. We’re determined to end surprise medical billing for American patients and that’s happening right now.” He thanked the mostly Republican group of lawmakers who came to the White House to discuss the initiative, including Senators Lamar Alexander (R-Tenn.), Maggie Hassan (D-N.H.), Bill Cassidy, MD (R-La.), and John Barrasso (R-Wyo.) and representatives Kevin Brady (R-Texas), Devin Nunes (R-Calif.), and Greg Walden (R- Ore.).

Trump then announced guidelines that the White House wants Congress to use in developing surprise billing legislation. They include:

  • In emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. “So-called ‘balance billing’ should be prohibited for emergency care. Pretty simple,” he said
  •  When patients receive scheduled non-emergency care, they should be given a clear and honest bill up front. “This means they must be given prices for all services and out-of-pocket payments for which they will be responsible,” Trump said. “This will not just protect Americans from surprise charges, it will [also] empower them to choose the best option at the lowest possible price”
  •  Patients should not receive surprise bills from out-of-network providers that they did not choose themselves. “Very unfair,” he commented
  •  Legislation should protect patients without increasing federal healthcare expenditures. “Additionally, any legislation should lead to greater competition, more choice, and more healthcare freedom. We want patients to be in charge and in total control,” the president said
  •  All types of health insurance — large groups, small groups, and patients on the individual market should be included in the legislation. “No one in America should be bankrupted unexpectedly by healthcare costs that are absolutely out of control,” said Trump

He noted that “we’re going to be announcing something over the next 2 weeks that’s going to bring transparency to all of it. I think in a way it’s going to be as important as a healthcare bill; it’s going to be something really special.”

Also at the announcement was Martin Makary, MD, MPH, a surgical oncologist at Johns Hopkins University in Baltimore. “When someone buys a car, they don’t pay for the steering wheel separately from the spark plugs,” he said. “Yet, in healthcare, surprise bills and overpriced bills are commonplace and are crushing everyday folks … People are getting hammered right now.”

Trump also introduced two families who had experienced high medical bills. Drew Calver, of Austin, Texas, said that after a heart attack 2 years ago, “although I had insurance, I was still billed $110,000 … I feel like I was exploited at the most vulnerable time in my life just having suffered a heart attack, so I hope Congress hears this call to take action, close loopholes, end surprise billing, and work toward transparency.”

Paul Davis, MD, of Findlay, Ohio, said that his daughter was billed nearly $18,000 for a urine drug screening test. “She had successful back surgery in Houston and at a post-op visit, because she was given a prescription for narcotic pain relief — which she used as directed — the doctor said, ‘Oh, by the way, I’d like to get a urine specimen.’ Fine; she did it. A year later, a bill showed up for $17,850.”

He noted that her insurance company’s Explanation of Benefits said that the insurer would have paid $100.92 for the test had it been done by an in-network provider. “This type of billing is all too common … The problem of improper billing affects most [of] those who can afford it least. We must put aside any differences we have to work together to solve this problem.”

“Today I’m asking Democrats and Republicans to work together; Democrats and Republicans can do this and I really think it’s something [that is] going to be acted on quickly,” Trump said.

Healthcare groups responded positively to the announcement, with one caveat. “The AHA commends the Administration and Congress for their work to find solutions to this problem,” Rick Pollack, president, and CEO of the American Hospital Association (AHA), said in a statement. “The AHA has urged Congress to enact legislation that would protect patients from surprise bills. We can achieve this by simply banning balance billing. … Untested proposals such as bundling payments would create significant disruption to provider networks and contracting without benefiting patients.”

“ACEP appreciates the White House weighing in on this important issue and welcomes congressional action to address surprise medical bills,” said Vidor Friedman, MD, president of the American College of Emergency Physicians (ACEP), in a statement. “Emergency physicians strongly support taking patients out of the middle of billing disputes between insurers and out-of-network medical providers.”

“ACEP is concerned about the administration’s call for a single hospital bill,” he continued. “Such a ‘bundled payment’ approach may seem simple in theory for voluntary medical procedures. But if applied to the unpredictable nature of emergency care, this untested idea opens the door to massive and costly disruption of the health care system that would shift greater costs to patients while failing to address the actual root cause of surprise bills — inadequate networks provided by insurers.”

The president also mentioned another one of his administration’s healthcare initiatives. “We may allow states to buy drugs in other countries … because the drug companies have treated us very, very unfairly and the rules and restrictions within our country have been absolutely atrocious,” he said. “So we’ll allow [states], with certain permission, to go to other countries if they can buy them for 40%, 50%, or 60% less. It’s pretty pathetic, but that’s the way it works.”

And now back to Medicare. As you all probably remember the reason that physicians decided not to support the national plan was the confusion regarding reimbursement or payment to physicians. But the insurance companies as well as organized labor who opposed the compulsory system on the grounds that its passage would deprive the labor movement of an extremely effective issue with which to organize workers.

Also, with the entry of America into the First World War the interest in the passage of a compulsory health care bill waned. Because of the anti-German hysteria, the AALL bill opposition became more organized with the biased thoughts that mandatory health insurance was the product of a German conspiracy to impose Prussian values on America.

Renewed interest in mandatory health insurance didn’t emerge until during the New Deal as a consequence of the report of the Committee on Economic Security, the committee appointed by President Roosevelt in 1934. As the Depression worsened the President and his advisors were eager to offer an alternative social welfare package. Roosevelt and his advisors particularly those of the Committee on Economic Security advised the passage of a comprehensive social security system to include unemployment insurance, old-age security, and government-administered-health-care insurance.

The final report by the Committee on the Costa of Medical Care was issued in 1932, by the Committee under the chairmanship of Dr. Ray Lyman Wilbur who was the former Secretary of the Interior and former President of the AMA. The Committee actually concluded that the infrastructure in medicine as well as the medical services in the United States were inadequate and made recommendations for changes. And, despite the favorable climate especially among labor leaders, politicians and social scientists the President’s Committee on Economic Security recommender unemployment insurance and social security but not the passage of a mandatory health insurance bill.

But Roosevelt wanted to keep the subject of health insurance and therefore established an Interdepartmental Committee to Coordinate Health and Welfare Activities immediately following the passage of the Social Security Act and ordered his staff to keep the subject out there before the public. Over the next few years it was the subject of many books and extensive studies by the federal government, but no bill yet.

More to come!!