Elyssa Durant
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Elyssa Durant Answering the call by asking the right questions...The Cost & Prevaleance of Chronic Conditions in the US By Elyssa Durant - Nov 17, 2009 10:26:44 AM ET Also listed in: Nashvillians for Obama | New York Action Team Cost & Prevalence of Chronic Conditions in the United States Statistics: Chronic Conditions Costs & Prevalence
Please forgive formatting errors: This document was created in 1996 and Blogger did not enter into my formatting plans... This was one of the most difficult posts for me publish because it was written before I incurred the debt of the population I was studying.
This is where I left off... perhaps someone has an idea where I can pick it back up...
Elyssa Durant/eds. October 27, 2009 13 years from the original date of creation... and life goes on ...
There is no effective system to care for those with chronic conditions in the United States; as a result, much of the care that is available is fragmented, inappropriate, and difficult to obtain. In comparison with acute conditions, chronic conditions call for a different kind of care: an integrated network of professional expertise. Chronic conditions do not always get worse; the health status of a person with a chronic condition can improve, deteriorate, or shift in either direction. The goal of chronic care is not to cure; rather, it should help individuals with chronic conditions maintain independence and a high level of functioning.
Problems encountered by people with chronic conditions
38% Cannot afford a service
19% Service not available when needed
15% Cannot easily get to a service
13% Quality of service so poor, won’t use it
11% Cannot find needed medical service
SOURCE: Chronic Care in America: A 21st Century Challenge. The Robert Wood Johnson Foundation.
The disproportionate use of health care by those with chronic conditions is consistent across all age groups, as might be expected given their greater health needs. Almost all (96%) of home care visits, 83% of prescription drug use, 66% of physician visits, and 55% of emergency department visits were made by persons with chronic conditions.
Payers: Over 40% of the direct health care costs for persons with chronic conditions were paid through public funds (Medicare, Medicaid, and other state and local medical assistance programs) in 1987. In contrast, public funds paid for less than 20% of the treatment for persons with acute conditions (Figure 2). Among the chronically ill or impaired, private insurance covers about a third of health care, while it covers 45% of the costs of persons with acute conditions.
Using the most recent data source available, we found that 90 million Americans had one or more chronic conditions in 1987. If the same age- and sex-adjusted rates of chronic conditions are applied, we estimate that the number of persons with chronic conditions in 1995 was almost 100 million.
The magnitude of this figure is important for several reasons:
1. First, because the number of persons with disabilities due to chronic conditions is more commonly and regularly reported in the literature, the total prevalence of chronic conditions has perhaps been minimized. The majorities of persons with chronic conditions are not disabled, but are living normal lives. However, they live with the threat of recurrent exacerbations, higher health care costs, more days lost from work than others, and the risk of long-term limitations and disabilities.
2. Second, persons with chronic conditions are at greater risk for being underinsured, particularly those with more than one chronic condition. Short and Banthin estimate 29 million nonelderly people with private health insurance are at risk of being underinsured defined as a function of a family's risk of incurring high out-of-pocket costs for medical services relative to their family income. We found that a disproportionately large majority of all direct health care services, including physician visits, prescription use, and persons with chronic conditions use costly hospitalizations. Their per capita costs are over 3 times higher than those of persons without chronic conditions are. Consequently, they are at greatest risk of unaffordable high out-of-pocket costs.
INSERT RWJF CHART SUMMARY ABOUT HERE
Persons with co morbidities are particularly at risk of finding themselves underinsured; their per capita costs are 2-1/2 times higher than persons with only one chronic condition are. Furthermore, high utilization rates make persons with chronic conditions less attractive to managed care plans that typically cover more services, including preventive care, with less cost sharing. Depending on the adequacy of their health benefits, even middle-income families (for example, a household income of $40,000) could quickly incur out-of-pocket costs in excess of 10% of their incomes if the only expense incurred in a year was to cover their 10% share for a surgery and hospitalization costing $50,000.
Reference:
Chronic Care in America: A 21st Century Challenge. The Robert Wood Johnson Foundation
The Chronic Care Perspective. The Robert Wood Johnson Foundation
[available: http://www.rwjf.org/library/chronic/chrcare/introfact2.htm]
Figure 1. Categories of disabling chronic conditions
Source: Institute of Medicine, 1991
categories of conditions diagnostic condition codes proportion of people
mobility limitations arthritis, paralysis 38%
chronic diseases asthma, cancer, diabetes 32%
sensory limitations blindness, hearing impairment 8%
mental limitations senility, mental retardation 7%
other conditions 15%
Chronic Care in America: A 21st Century Challenge. The Robert Wood Johnson Foundation.
Figure 2. People with chronic conditions report on their service system.
Source: Unpublished data from The Gallop Organization, 1992.
YES NO DON’T KNOW
Understand services you are eligible for? 47% 47% 5%
Understand how to use the services you are eligible for? 60% 32% 8%
Know who provides what services? 57% 38% 5%
Feel it takes more effort to use these services than they are worth to you? 36% 48% 16%
Mail to a Friend | Link | Comments (0) | Report to Admin Applying Federal Law to Support Mandatory Coverage By Elyssa Durant - Jul 25, 2009 9:59:01 PM ET Also listed in: Nashvillians for Obama Underwriting the Social Contract: Distributive Justice & Health Care ReformThe Problem Statement
As health care costs climbed exponentially in the 1980's, so did the cost of health insurance plans. As a result, employers began to enroll their employees in managed care organizations, and many Americans were forced to leave their traditional indemnity type plans. With the advent of the health maintenance organization, there is a financial incentive for the underutilization of care. (Blumstein, 1996; Davis & Shoen, 1996).
In order to reduce financial risk, health insurance companies have restricted enrollment to individuals in poor health. By covering the minimal standards of treatment and excluding high risk groups altogether, major US insurance companies have realized that the health insurance market can a be an extremely profitable industry. The public sector absorbs the cost of unreimbursed care for chronic care in America (Robert Wood Johnson Foundation, 1996). Based upon these findings, it seems clear that the money being removed from the health care marketplace is fattening the pockets of CEOs and majority stockholders.
Recent trend towards localized government leaves individuals without a financial safety net. This is the least efficient manner to handle health care costs, and evades the premise that medical care is a natural right in a civilized society. Few Americans feel secure within the current system. The rising costs of medical care contributed to the recent market changes in both the administration and delivery of health services. The financial incentive to cover only the healthiest individuals ignores the fact that medical care is a social good.
Health Insurance Portability Act of 1996
Two years after the Clinton Health Plan was defeated in Congress, Senator Ted Kennedy and Nancy Kassebaum introduced the Kennedy-Kassebaum Bill in response to growing concerns about selective enrollment procedures used by health insurance companies in the private sector. In the final version of the Bill, insurance companies must limit preexisting condition clauses to twelve months. It has been estimated that this provision of the Bill will help an estimated 150,000 Americans obtain health insurance coverage.
There are many levels of the underinsured, including those without any coverage; effective policy must address the needs of the total population without shifting costs from one disadvantaged person to another. Kennedy-Kassebaum fails to address the cost issue—the primary concern for those at risk for losing their health insurance. It does nothing to help the uninsured acquire a decent health policy, and then provides no solution to the critical issue at hand— cost
Since Kennedy-Kassebaum does nothing to control the cost of health insurance and medical care in America, the Bill fails to respond to the issue of greatest concern to the citizens of this country: the cost of medical care. The Bill looks towards the states to develop consumer protections and weakens the regulatory role of the federal government. The majority of the American public is unaware of the fancy footwork involved with this legislation, and the demographics of the population it is intended to protect. In order to assess the utility of this Bill, it is critical to identify the populations at risk for loosing health insurance coverage and the underinsured.
Kassebaum-Kennedy focuses on a slim portion of the uninsured population, and those who would be eligible for COBRA continuation (Consolidated Omnibus Reconciliation Act of 1974). Of the 41 million uninsured Americans, only about 150,000 are expected to benefit from this legislation. The Health Insurance Portability and Accountability Act of 1996 is really nothing more than smoke and mirrors since it fails to address the true issue at hand—the simple fact that the cost of quality health care in America is becoming a privilege that only the wealthy can afford.
The Cost of Care for Pre-existing Conditions
An individual with high blood pressure may just require prescription medication. Cancer patients in remission may require chemotherapy, and a person suffering with a degenerative disease may be involved in treatment studies. Each condition requires individualized treatment that cannot be based upon the simple economic/cost-benefit analysis used in the utilization review process by large insurance companies. Clearly, the most effective treatment for one patient may not be the best for another. The time required for utilization review may present additional health risks and complications to a patient suffering from a chronic health condition.
Twelve months without insurance coverage may be financially devastating to some patients, and 63% of Americans have already forgone some type of medical treatment within the last year due to financial constraints. Publicity surrounding Kennedy-Kassebaum has hailed the bill as the "be all and end all in progressive legislation, however, in actuality it will only help about 150,000 people.
Recent studies have found that the majority of the uninsured population simply cannot afford to pay the premiums (Donelan et. al., 1996; Hoffman & Rice, 1996). According to their data, only 1% of the Uninsured population is due to current health status and exclusionary preexisting clauses, yet an overwhelming number of insured respondents reported an inability to receive medical care for chronic conditions. The majority of Americans with chronic illness are covered by some type of insurance, yet they are still subject to the utilization review process and access problems that deny or delay medically necessary treatment (Donelan, et. al., Hoffman & Rice, 1996).
Underwriting the Solidarity Principle
Traditional forms of insurance underwriting required that the contract explicitly state which illness or services are not covered by the policy, in advance. If the underwriter did not specifically state a certain condition in the contract, the insurer was held to the terms of the contract and required to pay for services utilized by the policyholder (Stone, 1994, as cited in Durant, 1996).
Increasing numbers of for-profit and non-profit insurance companies began to control costs by refusing to insure individuals who they felt would utilize more services. Insurers began to require health survey status questionnaires (refer to attachment A), and even began implementing AIDS and genetic testing to identify high-risk individuals (Brunetta, as cited in Gutmann & Thompson, 1996). In the 1980s, large insurance companies began including sexual orientation as a high-risk category, by using actuarial sound criteria. Such criteria concluded that gay men were a higher risk for contracting AIDS virus and refused to write policies for anyone believed to be homosexual, (Stone, 1994 as cited in Durant, 1996).
By limiting enrollment to the healthiest members of society, selective enrollment undermines the solidarity principle of health insurance (Davis & Shoen, 1996; Snow, 1996; Stone, 1994). By eliminating those who were suspect of using more services than their healthier counterparts use, insurance companies are able to offer rock bottom prices for young, healthy individuals. By excluding preexisting conditions and requiring certain individuals to purchase high-risk policies, the number of uninsured and underinsured Americans continues to grow exponentially (Durant, 1996).
More individuals are choosing not to purchase insurance simply because they cannot afford it. Even among those with employer based health coverage, the policies frequently exclude coverage for long-term illness or care of chronic conditions (MSNBC News Forum, 1996). Without a standard definition of preexisting conditions, these clauses serve as "wildcards" since they allow insurers to deny coverage for any illness that "manifested itself before the issuing date of the policy (Stone, 1994 as cited in Durant, 1996).
This statement allows insurers to deny treatment for benefits and services for the policyholder for undiagnosed illnesses or conditions of which they were unaware. As a result, the insurers began to demand medical histories of applicants and their families in order to identify high risk individuals (please refer to attachment A).
Legitimacy of Distributive Justice
While there is a legitimate role of government to distribute scarce resources among the nation's neediest individuals, sadly this is not the cause for the mismanagement of medical dollars in the United States today. There is a big distinction between an individual being denied prescription medication at their local pharmacy due to a cost-effective formulary developed by their Managed Care Organizations (MCOs), than an individual being denied a liver transplant because healthy livers are a scarce resource. While both may have equally devastating consequences, it is more difficult to rationalize a lost life based upon rigid cost benefit analysis and utilization decisions made according to formulas and cost-benefit analysis of treatment protocols.
"The political controversy over the distribution of health care in the United States is an instructive problem in distributive justice. Good health is care is necessary for pursuing most other things in life. Yet equal access to health care would require the government to not only redistribute resources from the rich, healthy to the poor, and infirm, but also restrict the freedom of doctors and other health care providers. Such redistributions may be warranted, but to what level, and to what extent?" Gutmann & Thompson (Page 178).
Blendon and his colleagues have reported similar findings in public opinion polls from 1992 and 1994 (Blendon et. al., 1992; Blendon et. al., 1994). A recent study by the American Medical Association found cost to be of paramount concern to an overwhelming number of Americans (Donelan et. aI., 1996). Of the 40 million uninsured Americans, only 1% attributes their failure to acquire health insurance coverage to their preexisting conditions. Among the uninsured, cost is cited as the primary obstacle in obtaining health insurance coverage. Only 1% of the uninsured attributes their lack of coverage to a preexisting condition.
Based upon these democratic principles of distributive justice, consistent opinion polls demonstrate the legitimate role and public desire for government regulation of the health care industry. It has become obvious that the federal government must intervene in order to protect natural law rights, the social contract, and the Constitution of the United States. Regulation is needed to protect the individual freedoms, liberty, and the pursuit of "health, happiness, and the American Dream."
If America is to be the "Land of Opportunity," then clearly individual health and wellness should be an ideal to reach for. Current models of distributive justice emphasize public consensus as a legitimate role for government intervention. According to a number of studies by Blendon and his colleagues, the public has reported an overwhelming general concern about health care in this country, (1992, 1993, 1994, 1995, 1996).
State civil courts are backed up with cases where HMOs have violated the First Amendment (gag orders), the Fourteenth Amendment (due process), and the rights of protected classes under the Americans with Disabilities Act. Countless examples of "anecdotal" evidence appear as headlines everyday across the country. (New York Times, 1996; The New York Daily News, 1996; Long Island Newsday, 1996; LA Times, 1996; Picayne Times, 1996; Columbia Spectator, 1996; Columbia University Record, 1996; US News & World Reports, 1996; Newsweek 1996; Healthline, 1996; The Tennessean, 1996; The Albany Times, 1996; The Nashville Scene, 1996). In their entirety, these case reports represent the human tragedy that lies beneath the web of the very worst of American capitalism: corporate greed.
Identifying Populations At-Risk
A study by The Lewison Group in 1996 reveals insight into the private individual health insurance market. Clearly, individuals choosing to purchase health insurance policies for several hundred dollars each month expect their health care needs and expenditures to exceed that amount Regardless of health status, a young healthy 25 year old who purchases an individual health insurance policy can expect to pay well over $300.00 monthly for a health insurance policy with Empire Blue Shield Blue Cross (based upon 1996 rates, current rates available from the New York State Insurance Department).
Since individual policies are not addressed in the Health Insurance Portability and Accountability Act of 1996 (HIPA), an individual policy with Blue Cross Blue Shield of Tennessee excludes preexisting conditions for 24 months (enrollment booklet available upon request). The critical markets in need of reform are the adversely selected individual insurance market, and the state's most vulnerable populations: children; the elderly; the chronically ill; the uninsured; and the underinsured.
For the millions of individuals who have lost their employer based coverage, the cost of private health insurance is prohibitively expensive. Many individuals opt out of the individual market and apply for public assistance when the need arises. Those who have retained their health insurance coverage through their employers are being moved into managed care despite their efforts to retain their indemnity style plans (Davis & Shoen, 1996; The Lewison Group, 1996).
Access to Medical Care
As routine practice, HMOs deny or delay care for all services that are not outright medically necessary. Growing numbers of individuals have suffered irreparable harm, and many have died awaiting approval from their HMO's (The New York Times, 1996; Long Island Newsday, 1996; The Tennessean, 1996; Healthline, 1996). It is hardly a secret that HMOs have fallen short of their promise to provide comprehensive health care for the "whole" individual by emphasizing preventative medicine, using medical management to coordinate care. There is substantial evidence that individuals with chronic conditions receive substandard care in HMOs.
A four-year longitudinal study of medical outcomes found that the elderly, the poor, and persons with chronic conditions were in better health when covered by fee-for-service plans compared with a control group covered in HMOs (Ware et. al., 1996). New statistics released in Washington, DC by the American Medical Association and the Robert Wood Johnson Foundation revealed the direct costs of individuals with chronic conditions account for 75% of direct medical expenditures in the United States (Hoffman & Rice, 1996; based upon the National Medical Expenditures Survey; raw data available on CD from the Department of Health and Human Services Washington, DC). 45% of the American population suffers from at least one chronic illness.
If managed healthcare has been found to deliver inadequate care to this population, then we are looking at 100 million individuals who are potentially facing personal and financial crisis as they are moved into managed care. The public already accounts for the largest payment of direct medical expenditures, which means the millions of dollars being made by for-profit insurance companies are not being circulated into the economy to assist in public health costs care. The industry made a 14.8% profit in the 3rd quarter of 1996, however these medical dollars were removed from health care and used to fatten the pockets of CEO's and majority stockholders (Healthline, 1996).
Based upon a new report from the Robert Wood Johnson Foundation, the direct costs for persons with chronic conditions represent 69.4% of national expenditures in personal health care (Robert Wood Johnson Foundation, 1996). Their direct medical costs are estimated at $4672.00 annually compared with $817.00 annually for individuals with acute illness (Hoffman & Rice, 1996; based upon National Medical Expenditures Survey 1987, not adjusted for inflation). This population is the most vulnerable to complications in their health and with their source of payment. Large insurance companies only provide adequate coverage for acute illness (Donelan et al., 1996; Hoffman et. al, 1996).
Medicaid Managed Care
Following Tennessee's lead, many states have enrolled their medically indigent populations in Medicaid Managed Care Organizations (MCOs). In Daniels v. Wadley, (926 F. Supp. 1305), the court held that TennCare violated the Due Process Clause of the Fourteenth Amendment since such procedures eliminate fair hearings and independent medical review of disputes. The court found the pattern of routine denials of care by MCOs participating in the states TennCare program to violate the Medicaid Act since it compounded the problem of institutionalized waiting periods for medical appeals pending independent review by the Medical Review Unit (MRU), (42 U.S.C. § 1396 (a)(8)).
Furthermore, the court ordered federal injunctive protection to participants and beneficiaries because no state law may preempt federal law by depriving individuals of their constitutional rights. The Department of Health and Human Services (HHS) was ordered to revise its utilization review procedures for TennCare recipients in keeping with the Medicaid Act (42 U.S.C. § 1396 (a) (8)) ensuring due process protections for all covered beneficiaries by requiring "services are provided with 'reasonable promptness,'" (926 F. Supp. 1305).
This case is one of 543 civil suits pending in the state courts for violations of the Medicaid Act (based upon a Lexis-Nexis search performed December 26, 1996). With the passing of H.R. 3507 into public law, (The Welfare Reform Bill) private citizens will find little reprieve in the federal courts, so any attempts to hold states accountable for violations of federal law will be feeble at best (Denkeret. al., 1996).
Managed care has shown itself to be a farce of "medical management" in light of all the condemning evidence to the contrary. Timothy Icenogle, a medical doctor in the state of Arizona commented in 1981, "We play sort of an advocacy role. I think the public demands something more from physicians than to just be a blob of bureaucrats, and I think we have to take a stand now and then. Our role essentially as patient advocate, is to tell them, well, just because the insurance company is not going to pay, that is not the end of all the resources," (Icenogle, as cited in Gutmann & Thompson, 1996). Never has this statement been needed more than it is today. Unfortunately, as more insurance companies refuse to pay for medical treatment, fewer resources become available for patients in desperate need of financial assistance. As Judge Kessler eloquently stated as she handed down her decision in Salazar v. District of Columbia, No. 93-452, December 11, 1996, "behind every fact found herein is a human face and the reality of being poor in the richest nation on earth, (936 F. Supp. Slip op. At 3).
Perhaps most distressing is the lack of accountability for mismanaged healthcare and improper denials of medically necessary treatment. HMOs claim immunity under ERISA, and leaving individuals without recourse in a sea contractual language and lengthy court calendars. It is evident that individuals protected under the Medicaid Act are not fundamentally different from other populations entrapped in the maze of managed care. They are simply those who have "had their day in court."
Due Process Protections
Since all Americans are theoretically entitled to due process protections under the constitution of the United States, it seems the federal courts are long overdue for making such a public statement. We are wasting precious time and losing millions in valuable human resources as we await decisions to be handed down from state courts. The Supreme Court of the United States has agreed to hear New York's request for an ERISA (Employee Retirement Income Security Act of 1985) waiver, making health maintenance organizations liable for medical malpractice in the state of New York.
When HMOs deny care from patients, it is ludicrous to hold individual physicians liable for the utilization decisions made by decentralized corporate review boards. It is time to take a serious look at tort reform, and demand action by the Supreme Court as they approach the date of New York's ERISA hearing. A blanket court ruling upholding Daniels v. Wadley, and Salazar v. District of Columbia is desperately needed to avoid an avalanche of liability suits filed in state courts. The court must uphold Daniels v. Wadley, and Salazar v. District of Columbia if further lives are to be saved in medicine rather than wasted away in the utilization review procedures. While we wait patiently for District of Columbia circuit court to order injunctive relief, the number of individuals suffering irreparable harm due to the systematic denial of medical care grows larger each day.
The history of Medicaid Managed Care does not provide a very optimistic look into the future of TennCare recipients and Medicaid beneficiaries in states around the country. Dating back to the implementation of the Arizona Health Care Cost Containment System (AHCCCS) in 1981, there are documented cases where "people reportedly died for lack of medical treatment before their eligibility was determined," (Varley, as cited in Gutman & Thompson, I 996). This leaves me to wonder why the states continue to enroll their most vulnerable populations into a system of managed care that has proven to be a disaster.
Perhaps worthy of comment is that Arizona is the only state to have voted Republican in every election since 1948—certainly provides insight into the conservative morale of the state. Although Arizona was the last state to accept the Medicaid cost sharing incentive proposed by the federal government in 1966, it was the first state to force its medically indigent population into managed care in 1981.
Violating Federal Law
Rigid pre-certification requirements and nonspecific utilization review procedures place strategic barriers to access medical treatment and services in Health Maintenance Organizations (HMOs). Pre-certification requirements are strategic barriers incorporated into the "black box" of utilization review that institutionalizes exclusionary waiting periods and routine denials of medically necessary treatment. According to federal law, "care and services are to be provided in a manner consistent with the simplicity of administration and the best interests of recipients," (42 U.S.C. § I 396a (a) (19)). Clearly, such rigid pre-certification requirements that complicate administrative processing and paperwork on the part of the enrolled beneficiaries is a violation of United States Code.
Furthermore, using primary care providers as a mechanism to limit access to specialists not only complicates administrative processing, but limits enrolled beneficiaries choice of health professionals beyond what is available to the general public in the geographic area (42 U.S.C. § 1 396a (a)(30)(A)). Certainly referral procedures do not "assure that recipients will have their choice of health professionals within the plan to the extent possible and appropriate," (42 U.S.C. § 434.29). Under this provision, it seems that any individual, especially those with chronic health conditions or disabilities should be allowed
Mail to a Friend | Link | Comments (0) | Report to Admin Is A Pubic Option the Only Option? By Elyssa Durant - Jun 29, 2009 7:04:05 AM ET Also listed in: Nashvillians for ObamaAt 22 I was diagnosed with a degenerative spinal condition. Yes, there are times when the pain is so terrible, I cannot lifet myself out pf ed or tie my shoes. But far worse is having the knowledge that the level of damage to my spinal cord could have been stopped had I received adequate health care.
Yes, I had insurance. But who was there to make them pay???
14 years later, I finally received surgical intervention, and can feel my hands again-- and as a writer, that has been a miraculous gift.
Through the toughest times in my life, no one told me I was wasting my time and money on an education I would never be able to use.
After all I just wanted a diversion.
Even more disturbing than the damage to my spinal cord, is the realization that I missed mosre than 14 years of my life. So not only did I waste my time and money on an education I will never be able to use, I wasted a window of opportunity. A moment in time when I almost had a world the world at my fingertips.
Without any real place to go after college, I felt I had no other choice than to become a professional student of sorts—you know, the ones who stay in school forever to take advantage of cheap housing, health insurance, and student loans.
Unfortunately, I wandered aimlessly through the system acquiring useless knowledge and letters after my name that do not mean jack in the real world. But it distracted mye from the fact that my spinal cord continued to worsen my physical and emotional health.
So with no prosepects on the horizon-- and so thrilled thto feel my hands today, that the one thing I can do is write. So for now, I write, maybe tomorrow I'll read, but if there is any justice left in this world, maybe someday I will actually live.
http://darknightdurant.blogspot.com/2009/06/how-unemployed-pass-time.html
Mail to a Friend | Link | Comments (0) | Report to Admin Screw The Blues: Reform the Reform By Elyssa Durant - Jun 9, 2009 1:18:38 PM ET Also listed in: Nashvillians for ObamaI did not need another reason to demonstrate the need for immediate action concerning healthcare reform, however for those who feel Obama's current plan for reform is right on target, let me try to convince you otherwise. We need IMMEDIATE intervention.
However for anyone who needs to be reminded that we need to move forward, please read the excerpt below from KnoxViews:
"Blue Cross CEOs gorge on profits from premiums."
"The chief executive officer of Blue Cross of Tennessee got a big salary boost to over $2 million this year. Searches for "salary president ceo blue cross [statename]" will get you the figures for the rest of the states. To keep it simple, though, let's just assume that the 50 CEOs of each Blue Cross operation in each of the 50 states makes roughly what the top guy in Tennessee gets, Tennessee not being exactly one of the wealthiest states. That means we're looking at well over $100 million of our health insurance premiums poured into the homes, yachts, and kids' private schools of a tiny elite instead of going into the provision of health care for Americans."
-Vigil Proudfoot, KnoxViews available: http://knoxviews.mobi/node/11418
To learn that the CEO of Blue Cross Tennessee received a $2 million bonus is really not news at all. It is merely more of the same, and exactly what we can expect if the Healthcare Industry is expected to "curb" their spending. It just ain't gonna happen.
To learn that the CEO of Blue Cross Tennessee received a $2 million bonus is really not news at all. It is merely more of the same, and exactly what we can expect if the Healthcare Industry is expected to "curb" their spending. It just ain't gonna happen.
This just goes to show that we MUST have immediate intervention, regulation, oversight, and accountability over the Healthcare Marketplace. Not just the private companies such as Aetna or US HealthCare; make no mistake about it CMS Medicaid and Medicare have plenty of problems that must be addressed those programs are to intended to be the model for the rest of the country.
Obama's plan to come to the table with the Healthcare Industry is being passed off as Healthcare "reform" is a farce. The concept of self-regulation as the newest chapter in healthcare reform effort is a joke and my concerns continue to grow with each passing day. Since that compromise was made, have any of us seen any movement towards reform? Is there any evidence that we are moving toward covering the uninsured, lowering the cost of American healthcare or making it more accessible?
Asking or expecting the health industry to reduce costs through self-regulation without accountability is simply ridiculous. Especially when we see reports such as these that show a CEO salary of several million dollars.
Health care is already completely self-regulated and controlled. A person does not have free choice when choosing a provider. Due to an unholy alliance of provider networks, insurance underwriters, pharmaceutical conglomerates and private for profit hospital corporations such as HCA.
By negotiating with providers and developing one-size-fits-all prescription formularies and treatment protocols, we remove the ability for the consumer to make independent informed decisions about the value of various treatment options.
We rely upon one the ratings of physicians who have self-interest in controlling access and information to accurate information through their reliance upon Certification and Licensing Boards. By limiting access into the profession, health care costs are inflated and it is near impossible for the consumer to determine the fair value of a health care service.
Second, the consumer is far removed from the negotiating process, so we do not have a good sense of the fair, free market value of one particular service in comparison to another. All you need to do is look at any EOB (explanation of benefits) report for your last trip to the hospital.
Billing codes are used and assigned through various service departments and the insurance carrier then decides which services are covered and at what rate. They use the terms like “Reasonable and Customary Rates” and then choose to pay 80% of that amount. Therefore, by definition, that 20% must be built in to the billing rates to adjust for the actual (and expected) rate of reimbursement.
Such complicated billing procedures and methods are so complicated and technical that the end recipient of services (the consumer) really has no idea if an X-ray costs $90 or $73. Add into that a separate fee for the radiologist, and sometimes a charge just to use the facility, and even smart people find it difficult to understand.
The bills are then processed by an insurance adjuster who must determine primary and secondary (supplemental) plans and determine who is responsible for what, the end cost and intricate design is truly “priceless.”
Good luck to those people who actually purchased supplemental plans they saw advertised on TV, you have been duped. Giving people (especially the infirm and the elderly) a false sense of security is unfair and unjust.
Without regulation, intervention and enforcement, many people will continue to believe they are prepared and protected from that ultimate for “just in case” scenario that results in major, catastrophic medical loss.
The administrative cost alone on the part of the “Responsible Party” is probably more costly than the initial service they received at whatever hospital for whatever condition.
You cannot apply basic economic theory and free market principles to health care. Health care is fundamentally different and should be considered a public good.
We cannot believe or expect health insurance conglomerates will control their own spending and free from government intervention. We need to do something NOW!
Elyssa Durant, Ed.M.
Nashville, Tennessee
"You may not care how much I know, but you don't know how much I care!"
Available online:
http://thepowersthatbeat.blogspot.com/2009/06/screw-blues-healthcare-must-be.html
Mail to a Friend | Link | Comments (0) | Report to Admin Reform Requires Regulation By Elyssa Durant - Jun 7, 2009 9:15:51 PM ET Also listed in: Nashvillians for ObamaI have a serious problem with the most recent health reform effort. Asking or expecting the health industry to reduce costs through self-regulation without accountability is simply ridiculous.
Health care is already completely self-regulated and controlled. A person does not have free choice when choosing a provider. Due to an unholy alliance of provider networks, insurance underwriters, pharmaceutical conglomerates and private for profit hospital corporations such as HCA.
By negotiating with providers and developing one-size-fits-all prescription formularies and treatment protocols, we remove the ability for the consumer to make independent informed decisions about the value of various treatment options.
We rely upon one the ratings of physicians who have self-interest in controlling access and information to accurate information through their reliance upon Certification and Licensing Boards. By limiting access into the profession, health care costs are inflated and it is near impossible for the consumer to determine the fair value of a health care service.
Second, the consumer is far removed from the negotiating process, so we do not have a good sense of the fair, free market value of one particular service in comparison to another. All you need to do is look at any EOB (explanation of benefits) report for your last trip to the hospital.
Billing codes are used and assigned through various service departments and the insurance carrier then decides which services are covered and at what rate. They use the terms like “Reasonable and Customary Rates” and then choose to pay 80% of that amount. Therefore, by definition, that 20% must be built in to the billing rates to adjust for the actual (and expected) rate of reimbursement.
Such complicated billing procedures and methods are so complicated and technical that the end recipient of services (the consumer) really has no idea if an X-ray costs $90 or $73. Add into that a separate fee for the radiologist, and sometimes a charge just to use the facility, and even smart people find it difficult to understand.
The bills are then processed by an insurance adjuster who must determine primary and secondary (supplemental) plans and determine who is responsible for what, the end cost and intricate design is truly “priceless.”
Good luck to those people who actually purchased supplemental plans they saw advertised on TV, you have been duped. Giving people (especially the infirm and the elderly) a false sense of security is unfair and unjust.
Without regulation, intervention and enforcement, many people will continue to believe they are prepared and protected from that ultimate for “just in case” scenario that results in major, catastrophic medical loss.
The administrative cost alone on the part of the “Responsible Party” is probably more costly than the initial service they received at whatever hospital for whatever condition.
You cannot apply basic economic theory and free market principles to health care. Health care is fundamentally different and should be treated as such. Mail to a Friend | Link | Comments (0) | Report to Admin Bredesen is the Wrong Man for the Job By Elyssa Durant - Feb 12, 2009 10:04:35 AM ET Also listed in: Nashvillians for ObamaThere are widespread reports that Phil Bredesen of Tennessee is being considered for a position with the Department of Health and Human Services in Washington, DC. As someone who has lived and voted in the state of Tennessee since 1996, I have witnessed several shifts in policy, both on the local and federal levels. I am a recipient of TennCare, Social Security, and I a member of the Daniels Class. Governor Phil Bredesen has no place in Washington. Please remove his name from consideration for a cabinet position with HHS.
Governor Bredesen is currently "holding off in spending" until he learns what federal aid will become available to the residents of Tennessee. I am urging you to take immediate action. PLEASE sign the economic recovery package before it is too late.
Even under of the best of economic circumstances, the state has often been reluctant to release state monies until they are in physical receipt of all federal matching dollars. This delays program implementation and compromises the integrity of the research design. Consistency is a critical component of effective program development and design.
Governor Bredesen had decided to hold back state funds until the final details of the stimulus package worked out, were finalized. Anyone who has followed the healthcare crisis in Tennessee will tell you, Bredesen is not the champion of healthcare we once hoped he would be.
If we hold off on making decisions about the state budgets until the details of this enormous, comprehensive package are finalized, our current programs will suffer as a result. We cannot wait for a determination regarding federal funding before we to determine our state budget while before we of the programs we already are suffering financially.
Let me assure you that when it comes to withholding critical items like food, housing, social services, it adds up exponentially. Withholding medical care simply because of procedure and bureaucratic red tape, is shameful and cruel. The money is there, but it seems there should be a certain level of oversight and accountability if we expect it to be used effectively without delay and without excessive administrative delay and costs.
How do I know this? Because I used to work for the state during the time when they not only made the as they were transitioning to during the transition from I used to work for TennCare, We need to have some level of accountability to ensure the timely and proper disbursement of funds. In my experience, there is little recourse for person’s individuals who are caught up in the complicated payment arrangements, complicated language, and the systematic, procedural delay when it comes to the processing and payment of claims.
Let me personally assure you, that there is a very real human cost here as well... and unless there is immediate intervention, much more than just money will be lost. Please sign the bill before any more jobs, homes, and future are ruined by because help did not fast enough. Please release the funds, because we are running out of time.
I am 36, and my spinal cord is damaged from years of delayed, sub-standard medical treatment as I attempted to navigate a system that simply does not work. I owe the federal government $179,982.00 in student loans. When I am able to work, I make $10.46/hour as a substitute teacher in MNPS. That job comes with no security and no benefits.
I have an advanced master’s degree from an Ivy League Institution. I am nine credits shy of a Ph.D. in public policy. Despite having maintained a 3.83 grade point average while earning my masters, and just over 3.2 during the three years I was enrolled full time in a doctoral program.
Despite having comparable coverage, the insurance company refused to give me COBRA and would not cover my pre-existing condition even through both Columbia and Vanderbilt Universities used the same underwriter for student medical insurance: Chickering US HealthScare.
I had no break in coverage, and even purchased a private HMO (Oxford) plan that cost several hundred dollars each month just so I could prevent becoming uninsurable before my 25th birthday.
Wrong. Not only did I continue to pay for all three policies, I also had to pay for treatment and STILL wound up on TennCare and Medicaid.
Despite doing all the "right" things, I was still unable to transfer benefits from one graduate school to the next.
When I was twenty-two years old I developed a medical condition, and it quickly became obvious to me that it would be a lifelong struggle to cope and adapt to having physical disability. I purchased three independent policies, and was still covered under a terminal liability clause under a major medical ERISA (federal) plan. As someone who also needed to turn to federal funds and intervention in a crisis, I know that if or when help does arrive, it usually too late.
Where is the safety net? Where is the American Dream that I so diligently chased after for so many years? What was the point of investing so much in a future that I can never enjoy? How can anyone justify spending so money much on an education that will never be used? I understand the how; I just don't understand why.
Maybe one of these days Vanderbilt University and the Department of Education will realize it might just be cheaper to hire me that harass me. I need a real paying job now, but with the skyrocketing unemployment rate, it looks as though I will have a lot of competition.
Throughout the three year process of filing medical appeal after the next, I acquired over 1/4 million dollars in debt in unreimbursed medical care and student loans. I was fortunate enough be able t keep
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