Tag Archives: Affordable Care Act

Middle Americans Again Pays the Higher Price for the Affordable Health Care

It seems that when ever a law is passed that forces many to finance the cost of a program for all, that the big corporations can always fond a way to avoid the costs and the responsibilities that the rest of have to bear. Even better is that there develops another industry who benefits from finding ways around the laws.

Take for example the Manahatan-based startup called BeneStream who offer a subscription service to employers that analyzes the pay of each employee and help them enroll eligible candidates in the Medicaid program. This way the business can capitalize on language in the employer mandate, which will go into effect on January 1 that allows a family of four making less than $32,900 to enroll in Medicaid in lieu of private coverage. The so-called “employer mandate” requires companies with more than 50 full-time employees to provide health insurance will take effect, and commensurate surge of insurance business is expected to follow. BeneStream charges subscribers a one-time $40 registration fee and $200 annual maintenance fee per employee and estimates that between 20% and 40% of employees at hospitality and home healthcare companies are eligible for Medicaid.

This doesn’t sound too bad until you realize the future problems. First, more Medicaid patients in the healthcare system means that those patients covered by Medicaid will have to find physicians and health care systems that will provide services for the lowest paying insurance coverage. Many physicians now limit or deny coverage for the Medicaid covered patients. I myself as a health care practioner will not allow these patients into my practice due to the fact that Medicaid pays our practice basically 10 cents for every dollar billed when compared to what other third party insurance companies will pay. Most of the time, in a surgical practice, this will not even cover the overhead of the practice.

Also, companies can’t force employees to enroll in the Medicaid program, but they can encourage them strongly to do so by offering a plan that complies with the ACA’s minimum requirements, but provides less coverage than the Medicaid option, while simultaneously providing an easy pathway to enrollment in the government program. The BeneStream plan cost employers considerably less per employee than providing a private insurance plan that ensures that they avoid the expensive fines and penalties associated with flouting the employer mandate.

This then forces the middle class working stiff to come up with additional funding for the ACA through higher insurance premiums and higher deductibles to maintain a sustainable health care system.

“It’s a false promise of affordability,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms. “If you ever have to use the plan, you won’t be able to afford it.”

Remember that coverage through the Affordable Care Act is divided into five types of plans that require different levels of cost-sharing. Platinum plans pay 90 percent of medical expenses, on average; gold plans, 80 percent; silver plans, 70 percent; and bronze plans, 60 percent. Tax credits to help pay premiums are available for people with incomes up to 400 percent of the federal poverty level ($46,680 for an individual in the 2015 plans). In addition, a catastrophic plan is available, mainly to people younger than 30; it covers only limited services before the deductible is met and isn’t eligible for subsidies.

People are worried about being able to pay for health insurance. So the insurance industry and a group of Democratic senators have proposed offering cheaper, skimpier “copper plans” on the health law’s marketplaces that could draw in people who were unhappy with the cost of available plans.

But consumer advocates and others who study the insurance market suggest that there may not be a big demand for these plans and that they could expose people to unacceptably high out-of-pocket costs if they got sick, which includes the very higher, and in the future even higher deductibles. But the corporations are finding the ways around their responsibilities, just like their approach to paying taxes by having a European office or other foreign partner to avoid taxes, which the rest of we tax payers have to make up the deficit.

Professor Jason Reed made an interesting comment when he was discussing the March on Wall Street movement in order to understand economics and parasitism. A part of his lecture can be applied to our discussion: A successful parasite is one that is not recognized by its host, one that can make its host work for it without appearing as a burden. Such is the Ruling class and Big Business in a Capitalist society.

From the Patient’s Point of View-Why will they be Miserable?

 The 15-minute visits also take a toll on the relationship of the patient-doctor relationship. The patient who sits patiently in the exam rooms waiting patiently for the doctors to arrive for their visit and to finally speak with their physician. They have already seen the administrative secretary and the nurse, but they came here to see their physician. So, now the physician presents his or herself. Based on my complaint he or she looks in my mouth, throat and up my nose, said that my throat was inflamed and told me to see the nurse for a prescription and that I was suffering from a sinus infection with inflammation of my throat from posterior pharyngeal drip.

When I protested the drug that he wanted to prescribe he cut me short and told me to see the nurse……and he was out of the exam room. It must have been a visit that lasted for a total of 9-11 minutes, if that.

This story is becoming increasingly common. The patients as well as the physicians are feeling the time crunch as never before. The doctors and nurses feel like “running” office hours on rollerblades. Doctors have to see more patients and perform more procedures to make up for the discounted, flat or declining reimbursements.

This problem will worsen with the Affordable Care Act (ACA). Remember, millions of consumers who are gaining healthcare through the ACA begin to seek care, many of whom have never, or very rarely, have seen a doctor and therefore this patient population presents with a list of untreated problems. Often in the primary care as well as in other specialties, the patient is seen for only one diagnosis per visit. This is very inconvenient for the diagnostically/multiple disease patient. They then don’t get the comprehensive care with continuity associated with the individual patient. This is happening today as evidence by one of my patients with complex endocrine disease (diabetes and thyroid disease) who has been frustrated by these short visits with the results that her complex disease is out of control. I quickly referred her to an endocrine specialist.

In today’s world it seems that the doctors have one eye on the clock and the other on their laptop computers, typing away to capture the correct amount of “points” for the highest reimbursement for the visit.

As Roni Caryn Rabin stated in her article in WebMD, short visits take a toll on the whole relationship of the doctor –patient, which I have already stated in an important part of the good care equation. As I presented last week, we have to have a change in behavior in both the doctor as well as the patient. The office visit and the physician-patient relationship represents missed opportunities for getting patients more actively involved in their own health care. Research and the surveys show that there is less of a dialogue between the patients and their doctors, which increases the odds that patients will leave the office frustrated. Also, the shorter visits also increase the likelihood that patients will leave the office with a prescription, instead of discussion about behavioral changes like trying to lose a few pounds by going to the gym/exercise.

The physicians also don’t like to be rushed either, but for the primary care physicians and now even with specialists, time is is, quite literally money. Primary care doctors are paid mostly per visits with only minor adjustments for those that go longer than the time allocated for the diagnostic codes. Specialists who do procedures also need to see an increasing number of patients to generate a proportion of patients an increased number of procedures to compensate for the decreasing/discounted reimbursements for those procedures. The struggle is getting worse and worse with doctors thinking about meeting the bottom line, paying the overhead, having to pay staff and keep the doors open.

The pressure becomes even worse between both physician and patient when the patient has waited 9 months for his or her appointment and when the doctor comes in the exam room the patient pulls out a long list of complaints. Remember, the patient is thinking that they have waited sometimes a few months for the appointment and I’m going to try to get the most of my time that I have taken off from my work or have had to get paid childcare so that they could get to the appointment.

The situation became worse when doctors started participating in managed care networks where the doctors gave the insurers discounts on their rates in exchange for the promises to steer more patients to their office. Therefore, to avoid a cut in income the doctors had to see more patients.

In medical school the students are drilled in the art of taking a careful medical history, but studies have found that the doctors are falling short and that they have a bad habit of interrupting. A 1999 study of 29 family care practices found that doctors let patients speak for only 23 seconds before redirecting them and that only four patients got to finish their statements. Today the technical doctor of the present is often, and the interview is interrupted by the physician’s beeper, their cell phone or an email notification as their typing in the patient information on their laptops.

Communication between the physicians and their patients is important and making the patient feel they have been heard may be one of the most important elements of the healthcare equation. People are feeling dissatisfied when they don’t get a chance to say what they have to say, when they don’t get their questions answered, that they got their monies worth.

What happens when the patient doctor relationship suffers? Well, the patients lose trust in their caregivers and don’t fully engage in their care. How then do you change the patient’s behavior leading to better care, a healthy patient that leads to a more sustainable health care system?

It is predicted by this writer and physician, that with the increased numbers of patients forced into a system with less and less physicians that this relationship between the physician and their patient will get worse and worse. So, the middle class will get poorer healthcare and have to pay more for it.

Myth of Health Care Charity


First, before I initiate a discussion regarding charitable health care, let me question the intelligence of voters in the State of Maryland. I already discussed weeks ago regarding the horrendous roll out of the Maryland healthcare system under the Affordable Care Act (ACA). Who was responsible? The Lieutenant Governor of the State of Maryland, Anthony Brown was responsible and he botched up the roll out eventually costing the taxpayers of Maryland about $200 million. However, the campaigning lies are promoting the wonderful job that he did regarding the ACA. The latest TV ad suggests that he did so much, especially for the aged/seniors. Those that know anything and have minimal intelligence, probably the minority of voters, realize that the seniors/aged are covered by Medicare and have very little to do with the roll out of the ACA. So, as I have said multiple times, wake up America, wake up Marylanders!!

Now on to our Sunday evening discussion.

Anne Zieger reported that in an effort to force patients to buy policies through the ACA health insurance exchanges, hospital systems around the country have started cutting back on financial help for lower- and middle-income people who don’t have health insurance. They are assuming that these families can afford the health insurance plans offered on the exchange, but have declined to make the investment.

While the number of systems that are taking this tack seems limited so far, many hospitals and health systems are considering a “get tough” approach to charity care, and experts predict that that more restrictive policies will become increasingly common, according to the piece in The New York Times. The State of Maryland is different because has waivers for uncompensated care as well as a TPR or total payment system.

One example that stood out in the Times piece comes from St. Louis, where Barnes-Jewish Hospital has started charging copayments to uninsured patients, no matter how little money they’ve got. Another example comes from the Southern New Hampshire Medical Center in Nashua, which no longer provides free care for most uninsured patients above the federal poverty line of $11,670 for an individual. Yet another hospital taking a stricter approach to the uninsured is Burlington, VT-based Fletcher Allen Health Care, which has cut back on financial aid for uninsured patients who earn between twice and four times the poverty level, the Times piece notes.

Unfortunately, these providers’ assumptions about patients’ ability to pay are incorrect. Those at or near the poverty line may not be able to afford even heavily-subsidized policies, and the middle class — who get little or no subsidies — often find that the hundreds of dollars a month they are expected to pay is far beyond their reach

The open but little-discussed secret to the health exchanges is that they really haven’t made health care that affordable after all. In Virginia, for example, the cheapest policies are approximately $350 per person with a $4,000 deductible and a 20% coinsurance requirement. Not only is that a sizable premium level even for middle-class family, the deductibles and coinsurance requirements reduce the value of such a policy dramatically, as low- and middle-income families are seldom equipped to meet such deductibles and coinsurance requirements. Here in Maryland we are seeing deductible as large as $5,000-$7,500 with insurance premiums rising by 42-50 percent. Therefore, they now have catastrophic care insurance policies. Who is winning in this scenario? Not the insurance companies! No, once again, as I have previously pointed out, it is the middle class working tax paying person who is footing the bill for the ACA and who suffer the most.

Health systems are continuing under this assumption as though this were a reasonable option, and that the less prosperous patients are simply being intransigent. “Do we allow our charity care programs to kick in if people are unwilling to sign up?” Nancy Schlichting, chief executive of the Henry Ford Health System in Detroit, asked the Times. “Our inclination is to say we will not, because it just seems that that defeats the purpose of what the Affordable Care Act has put in place.” 

Another hospital, Southern New Hampshire Medical Center, had previously provided free or discounted care for patients who were at or below 225% of the poverty level, or about $26,260 for an individual. Now, however, patients who “refuse to purchase federally mandated health insurance when they are eligible to do so will not be awarded charitable care,” the hospital’s new policy states. Notice the use of the word “refuse” — it implies a lot that’s simply not true about the uninsured.

Ultimately, all of this posturing is in vain, and merely punishes lower-income patients to no avail. If hospitals hope to save money by cutting back on charity care, they’re probably out of luck. If a family can’t afford premiums on the health exchange, they aren’t going to be able to pay massive hospital bills either.  Depriving them of charity care won’t magically force them to take on a larger percentage of their hospital bill, it will simply increase the level of bad debt a hospital must account for, and what’s more, makes it more likely that frightened consumers won’t come in to the hospital for help when it’s needed.

It’s understandable that hospitals want to see the health exchanges work, and want to see as many lower income people buying policies on the exchanges as possible. After all, that does give them a shot at reducing their bad debt.  But if they really want to deal only with insured patients, it’s time they gear up campaigns to subsidize health exchange premiums through thirdparty payers, a strategy that actually has a chance of working. Taking a position that tries to force the poor to produce premium funds out of thin air is just plain wrong.

But also, expecting the middle class to shoulder the high premiums as well as having to deal with extreme deductibles makes no sense. We, as physicians, are already seeing patients cancel their office visits, surgery and routine diagnostic tests, which can and will lead to poor care and delayed diagnosis of diseases. Therefore, they delay treatment leading to more extensive surgical procedures, additional chemotherapy and or radiation with threat of recurrence of disease, cancers and additional treatment.

A recent “edict” was passed in Europe, which we should all pay attention. In discussing affordable health care, socialized medicine or what ever you want to call it in the European countries we want to evaluate how these countries pay for health care. The British Isles depends on the Value Added Tax or VAT tax. Up until this recent change the tax was 17%. However, change is coming in two phases. Number one is the use of co-payments, which haven’t been part of the system since the 1940’s. Number two is the raising of the VAT tax to 27%. Yes, a tax elevation of 10%.

We will spend more time reviewing and evaluating the ACA, other comparative systems and hopefully will strategize modifications to the ACA, if possible.

Memorial Day Review of Affordable Health Care

Looking at the key provisions of the ACA:

▪   Basic benefits package defined by the federal government

▪   Increased Medicare payroll tax on upper income earners

▪   Penalty for employers (with 50+ employees) who do not offer healthcare

▪   If an employer doesn’t offer insurance, people will be able to buy it directly in the Health Insurance Marketplace.

▪   Tax credits to small business – by 2014, 50 percent of the employer’s contributions.

▪   The Medical Loss Ratio. At least 85 percent of all premium dollars collected by insurance companies for large employer plans must be spent on healthcare services. For plans sold to individuals and small employers, at least 80 percent of the premium must be spent on benefits.

▪   Eliminating annual limits on insurance coverage for new plans and existing group plans.

▪   No out-of-pocket for many preventive services. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance.

▪   Children up to age 26 can stay on their parent’s health insurance plan.

▪   No denial of coverage due to a pre-existing condition.

▪   Insurance companies cannot limit the coverage someone receives over his or her lifetime.

▪   Expand who will be eligible for Medicaid. States will receive 100 percent federal funding for the first three years, phasing to 90 percent federal funding in subsequent years.

▪   The law provides consumers with a way to appeal coverage determinations or claims to their insurance company.

▪   Tax credits for middle-low income uninsured. These individuals may also qualify for reduced copayments, co-insurance, and deductibles.

▪    The Individual Mandate. People who are not already covered or fully subsidized will be required to purchase coverage or face a penalty – with some eligible to receive subsidies towards private insurance premiums.

Vincent Vallejo on August 20, 2013, in the Banktec report, reviewed four observations on how the Affordable Care Act will impact healthcare business process outsourcing (BPO)., which are continuously being developed to decrease the administrative burden

With the ever-changing landscape of the U.S. healthcare system, the U.S. healthcare business process market is undergoing a significant transformation. This year, the U.S. healthcare payer, provider, and pharmaceutical outsourcing markets are valued at $11.1 billion, $6.8 billion, and $65.6 billion.

Today’s healthcare industry generates more than 8 billion claim transactions annually, resulting in $2.7 trillion worth of payments processed through a network of costly channels. Unbelievably, a huge percentage of the processing of these transactions is done manually and on paper – resulting in massive inefficiencies and high-dollar write-offs, estimated to exceed $92 billion each year. A healthcare provider’s back-office is typically buried in mountains of claim and payment paperwork. Duplication is rampant, two to three intermediaries handle transactions, payment to providers is always slow – the cost to providers is staggering. The object of outsourcing in healthcare is to:

▪   Improve efficiency and reduce costs

▪   Improve collections and increase yields

▪   Help eliminate write-offs

▪   Enhance in-process claim visibility

▪   Improve provider/patient relationships


1. The Medical Loss Ratio does not offer a clear means to lower administrative costs. Thirty cents of every dollar spent on healthcare in the U.S. goes toward administrative costs. While the law says to lower these costs, it doesn’t offer a clear path to make this possible. The law provides for small businesses needing to offer insurance to its employees. The law provides tax credit to middle class families and expands Medicare to the lower class. However, payers and providers are left to figure this puzzle on their own.

 2. Business Process Outsourcing can alleviate the Medical Loss Ratio burden. Services to assist providers in payment reconciliation, denial management and re-billing disputed claims can increase providers’ revenues by as much as 3 to 5 percent. In order to comply with the Medical Loss Ratio, every percentage point counts. The healthcare industry will discover what large corporations have always known. Outsourcing high-volume, data-intensive business processes can drive down costs.

3. Providers will be motivated to claim every dollar available to remain profitable. Healthcare providers write off over $92 billion per year due to an inability to get accurate and timely claim and payment information. BPO companies do not just offer savings on administrative personnel. By improving the process, providers can make more money from abandoned claims. Business process outsourcing companies streamline the revenue cycle and make the payer-provider relationship more efficient.

 4. The Affordable Care Act requires standardized billing and an electronic exchange of health information. More than half of transactions between payers and providers are paper-based – significant contributor to the high cost of healthcare. Healthcare remains one of the few industries that relies on paper records. A BPO company with expertise will be able to clear out the warehouse of dusty paper records and replace it with fully secure, searchable data.

The Affordable Care Act is large and complicated, but outsourcing solutions exist to simplify the added administrative burden, which we will discuss further in future blogs.

Over the last many weeks we have discussed a number of pros and cons regarding the Affordable Care Act. Whether we want to argue the nature of free health care for all and the constitution, the fact is that health care for all is a great concept. Yes, our health care system is broken or sick and that it is considered to be the most costly with an extremely poor return on investment. Why?

The answer is simply yet complex. Our rights, our freedom, and desire to make money, allow us to make bad decisions and with no cost consequences. We demand CT scans or MRI’s when we get headaches at no cost to each of us and “forcing” the health care worker to provide these expensive tests to cover “their behinds” so that they won’t get sued.

Traditional medicine and our freedoms are making us sick. We as a notion lack self control and the results are that chronic diseases such as heart disease, stroke, cancer, diabetes, and arthritis are among the most common and preventable of all of the problems on the US.

I site the Mark Twain quote: “The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you druther not” That is, the four modifiable health risk behaviors that we just fail to improve are the lack of exercise or physical activity, poor nutrition, tobacco use and excess alcohol consumption. As Ron Graham further discusses in the Healthcare blog, these health risk behaviors are responsible for much of the high health care cost, illness, suffering and early death related to the chronic deases that we discussed. Consider that the latest reported obesity rates is the US is 27.7%. Unbelievable!

How then can we improve the health care system if we “give” insurance coverage without consequence for bad behavior?

So, go have a wonderful Memorial Day picnic and think and chose healthy while you prepare, cook and eat at your holiday outing.

Does the Affordable Care Act Work?

Today is Easter Sunday, which is a time of reflection and renewal for those of the Christian faith. Easter is also a time when we reaffirm family traditions and break bread with our friends and loved ones. I’m hoping that everyone had a wonderful Sunday no matter what your religious beliefs and what holidays you celebrate.

It brings to mind an article that Dr. Ben Carson wrote and appeared in today’s Opinion section of our local newspaper: Recovering America’s exceptionalism. He reflects on the famous French historian Alexis de Tocqueville, who came to America to study our nation. He concluded his American analysis by saying, “America is great because she is good. If America ever ceases to be good, she will cease to be great.” Interesting observation. Our we seeing the degradation of our greatness??

Dr. Carson delves into religion, slavery and history. He further discusses the wisdom and goodness of learning from our mistakes. He finds it “disturbing in the pursuit of goodness the turning of a blind eye toward corruption, much like the Romans did before the fall of their empire.” He is concerned regarding scandals that been characterized as “phony scandals” based on politics and “tells you a great deal about the loss of honesty in our society.”

So, how does this discussion fit our discussion of the Affordable Care Act? “The fact that one party is willing to use its majority status to cram a health care bill down the throats of the minority party and the American people and then refuses to acknowledge the obvious illegitimacy of a bill passed largely on the basis of false information provides a barometer on the lack of importance placed on virtue in our society today. How can such a society in any way claim to be good?”( The Sunday Star, April 20, 2017, Page A7).

My son this weekend, after a number of frustrating discussions with me, his mom and his friends, asked the question-What is really wrong with “Obamacare”? It really seems like such a great idea. My very intelligent wife then pointed out reality to the younger generation, who will soon see the obvious errors of the Bill. She realized the fallacy of the design when she was notified of her huge jump in our health insurance premium as well as the more than doubling of our deductible. She is now considering the delay in many of her doctor visits and diagnostic tests/exams.

Interesting and it brings up the major topic of discussion of this weeks blog. Read on.

Normally I appreciate and respect the opinion of Donna Brazile, appearing many times in our local opinion section of our and I’m sure many other newspapers.

In her article “Health care works on many levels” she tries to point how well the ACA works for the enrollees. As she ends her rant, she states “Numbers do not measure the ACA’s sign-up success. As a result of the Affordable Care Act- Obamacare- illnesses are prevented, people have a greater security in their lives, more money in their pockets (because insurance companies can’t make a profit higher than 20 percent), and families have a parent or child with them because a disease was cured. These are the true measures of success. And that is priceless” (The Star Democrat, April 9, 2014, Page A4).

My problem with these comments and the whole process is what we are really seeing in our medical practices. That Middle Class Americans are really being missed or made to bear the burden/cost again of the “real” health care solutions. Also, the numbers may really do measure the sign-up failure and the failure of the bill/law itself. We need to evaluate the breakdown of the enrollee numbers carefully.

Our President, when he first got into office, stated that he was going to protect the middle class of America. However, the middle class enrollees have had their insurance premiums increased by double digit percentages as well as have had huge increases in their deductibles, as I cited with my wife’s experience. They then are delaying their routine follow-ups for primary as well as specialty care as well as diagnostic tests and even surgeries. How does this prevent illnesses, give people a greater security in their lives or more importantly, keep more money in their pockets? In fact with the increase in deductibles, as seen by examples of $ 4,500 on average, they are now paying more out of pocket portions toward their health care bills. I was pulled aside by one of my”former”patients,who wanted to apologize for having to cancel his routine cancer post operative exams. He explained that his deductible of $5,000 made it very difficult to see me as well as his primary care doctor. Again, this is reality not media hype!

To the rich, this probably will never be a problem or a concern for this group. The poor, who is the only group that this program will help, are not going to contribute to the sustainability of the system. Paying $66-$110 toward their health care insurance coverage does little to cover the costs of health care. Unless health care system pays very little to the doctors and nurses who are given the job of caring for the increased numbers of patients that are going to seek care. Also, the statistics show the enrollees represent a sicker portion of the patient populations. This represents a more costly group of enrollees to treat. Yes, the government is going to subsidize this group of patients, but where are we going to see evidence of sustainability? We do need to see evidence of young, healthy enrollees who can afford the huge premiums and deductibles to assist in sustaining the health care system.

So, Chris, my son with the questions, read on as I attempt to point out the problems with the ACA. But unlike most of the people that object to the Bill and try to repeal the Bill, let us see if there is a way to make it work and provide what the President really wanted- a valuable health care program for all. Is there anything wrong with this goal? No, as long as the population for which it serves realizes the limitations and what is required by all of the enrollees. Look to the British health care system and their problems!