Republicans are promising that they care about pre-existing conditions. But you if you have a pre-existing condition, you should be freaking out.

As a practicing physician for going on nearly 50 years now, I often feel like that auto insurance company that says “We know a thing or two because we have seen a thing or two.”

After years of dealing with people who are insured, people who are uninsured and health insurance companies, I know that having real, comprehensive coverage can mean the difference between life and death.

A few years back, one Republican Congressman – speaking about the impact of GOP legislation that would have drastically cut Medicaid – defended the plan he supported by stating, “Nobody dies because they don’t have access to health care.”

That false assurance has been widely debunked by people who actually report on health reform or work in healthcare. But that hasn’t stopped critics of the Affordable Care Act from continuing to promise “Relax. We’ve got this” … all the while promising to dismantle a law that greatly expanded access to affordable health coverage for millions.

Pre-existing conditions are a matter of life and death …

The current ongoing line of false reassurances has to do with health coverage for people with pre-existing conditions. Many Republicans are on the campaign trail right now claiming that they’ve been protecting folks with pre-existing conditions all along. And these would be the same people who voted for the American Health Care Act in 2017. (The AHCA, passed by the GOP House last year, would have stripped health insurance away from people with pre-existing conditions, had its passage in the Senate not been derailed by late Sen. John McCain.

The folks who wrote the ACA bent over backward to ensure that protections for millions would be a central plank of the law:

Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.

… for millions of Americans.

In 2017, about half of non-elderly Americans – or about 130 million non-elderly people – had pre-existing conditions in the U.S., according to a brief from the U.S. Department of Health and Human Services.

Nationally, the most common pre-existing conditions were high blood pressure (44 million people), behavioral health disorders (45 million people), high cholesterol (44 million people), asthma and chronic lung disease (34 million people), and osteoarthritis and other joint disorders (34 million people). – U.S. Department of Health and Human Services

More and more people are beginning to understand that. Of American voters, 66 percent of registered voters said that continued protections for people with pre-existing conditions was either the “single most important factor” (14 percent) or a “very important factor” (52 percent) in their vote for a candidate. (Which explains why the GOP is suddenly claiming they love these protections.)

Who are these people with pre-existing conditions?

If you don’t have a pre-existing condition – or you can’t think of someone right off the top of your head who might have one – let me offer a glance at some of your fellow Americans whose stories as patients have crossed my desk over my years as a Physician Executive.

Patient #1: Atrial fibrillation

This middle-aged female was sent to the Emergency Department by her cardiologist because of symptoms that  included a five-day history of palpitations (feeling heart beat in chest), dizziness (imbalance) and headache. The EKG showed Atrial Fibrillation with a rapid ventricular response. She also had an elevated blood pressure that was persistent. The admitting diagnosis was new onset atrial fibrillation with rapid ventricular response.

Result: This patient now has developed the dreaded “pre-existing condition.”

Patient #2: Herniated disc

This 30-something male patient had a 12-year history of a herniated disc. He presented to the Emergency Department with back pain and sciatica going into his left leg, associated with difficulty walking. A CT scan indicated a disc protrusion in the lower back.

This patient had a medical history of a weightlifting injury and known herniated disc. On top of that he presented with a two-week history of gradually increasing low back pain with sciatica. The pain was impacting his ability to walk. An MRI revealed the thecal sac at the nerve root was indented. In layman’s terms, that means the arthritis of the spine was putting pressure on the nerve.

Result: Patient #2 had a pre-existing condition and could be denied health coverage.

Patient #3: High blood pressure, heart disease, chronic lung disease

A middle-aged female patient came to the Emergency Department complaining of a pounding headache located mostly in her forehead, associated with lightheadedness. The patient had a medical history of high blood pressure and heart disease but had not taken her blood pressure medication due to financial reasons for at least two months.

The patient also had a history of mild atrial fibrillation and chronic lung disease, but the patient reported that she had not had treatment for those. The patient also reported swelling in her lower extremities for which she took an over-the-counter medication.

Result: This is not an unusual scenario in today’s healthcare landscape. And this patient could be denied coverage for these pre-existing conditions.

Short-term plans

While Republicans did their level best in 2017 to pass a law that would erode protections for folks like the three examples above (and many more), President Donald Trump has been providing his own false assurances about about health coverage. His promise: that Americans can relax, because he’s coming to the rescue with more (and CHEAPER) short-term health insurance alternatives.

Short-term coverage is not an ideal solution for people with pre-existing conditions. The plans:

• aren’t required to cover ACA’s essential health benefits;
• may deny you coverage if you have pre-existing conditions;
• may require pre-certification for many medical services;
• will likely screen applicants through medical underwriting;
• impose annual and lifetime benefit maximums.

In October, new federal rules expanded the duration of short-term health plans in many states. But other states have taken a “buyer beware” approach and a handful of states – including New York and New Jersey – completely ban the sale of short-term health plans.

Lack of insurance can kill you.

So let’s go back to the original point of this column: that pre-existing conditions are a matter of life and death. They most definitely are – because having a pre-existing condition in the ‘good old days‘ before Obamacare meant that getting comprehensive health coverage on the individual market was difficult or near impossible.

But can being uninsured really kill you? From my literature review, it’s clear that you are from 3 to 29 percent more likely to die if you don’t have health insurance than those who do!

Here’s some of research:

• In 2002, the Institute of Medicine estimated that the “death rate of the uninsured is 25 percent higher than for otherwise similar people who have health insurance. According to the study, 18,000 excess deaths occurred each year because 40 million Americans lacked insurance.”
• In January 2008, the Urban Institute updated that study. “Subsequent research has continued to confirm the link between insurance and mortality risk. The true number of deaths resulting from un-insurance will be “significant.”
• A 2009 rebuttal study by the Health Research and Education Trust found that “when adjusted for health status and other factors, the risk of subsequent mortality is no different for people who lack insurance than for those who are covered by employer-sponsored plans.” But the study also had a second conclusion: “With health status excluded, the uninsured have a 10 percent higher mortality rate than similar insured persons.”
• The Harvard researchers compared 2001- 2005 death rates in Massachusetts to the four-year period after a new healthcare law was enacted and found that “mortality rate decreased by 3 percent between 2006 and 2010 when greater access to health care may have prevented as many as 320 deaths per year. Providing health coverage to 830 uninsured adults prevented one death per year.”
• A 2012 New England Journal of Medicine study analyzed the effects of Medicaid expansion on adult mortality in several states. It found a connection between access to Medicaid and reduced mortality: the exact figure was a 6.1 percent reduction in mortality.
• The Center for American Progress projected what would happen if the NEJM results were applied to the states which had not expanded Medicaid. “In these states alone more than 12,000 lives per year could potentially be saved if state governments agree to expand their Medicaid programs.”
• In 2017, the Congressional Budget Office (CBO) predicted that 22-24 million Americans would lose coverage under the AHCA. If 3 percent of these Americans died presumably because of this impediment to receiving healthcare, then 720,000 Americans might have died because of that lack of coverage over time.

It’s time to pay attention.

The Congressman at the start of this column also famously stated that “Nobody wants anybody to die.” It sounds great – and it’s a notion that most of us can probably agree with.

But at this critical juncture in our nation’s healthcare history – when Americans are more concerned than ever about losing the protections they gained from the ACA – we must pay even closer attention.

We must closely examine our candidates’ voting records on healthcare. We must not simply nod our heads at last-minute promises about preserving ACA’s protections. We can’t simply decide that cheap coverage is good coverage.

We should know better. After all, we’ve all “seen a thing or two.”

Information source

Most Americans get their insurance from their employers. Yet how much do individual employees really know about how health plans work? For many, the story has not been particularly pretty of late: rising employee premium contributions, rising deductibles, rising co-pays and co-insurance, rising out-of-pocket spending.

It’s no secret that our health care system is underperforming or in crisis on many different fronts: legislative gridlock, high costs, poor performance overall compared to other nations, etc.

But as an employee, would you feel better — or at least empowered — if you had a handle on how the employer system works? Or are you fed up with reading about health care?

If you’re an employer, you’re probably a user of the system too — and chances are you’re looking for ways to beat back health costs for your business.

A new book by Dave Chase, a serial entrepreneur who wants to remake the health care system, might just confirm some of your suspicions about how badly the system is broken. The book is called “CEO’s Guide to Restoring the American Dream,” with a subtitle “How to deliver world class healthcare to your employees at half the cost.” Chase is also co-founder of the Health Rosetta Institute, which seeks to further these goals. I caught up with him the other day to ask him a few questions.

(Disclosure: Chase and I chat from time to time, though we do not do business together. He asked me to write a chapter for the book about how cash prices in health care stay relatively flat, while everything else — premiums, deductibles, employer spending — always goes up, based on a blog post that I had written previously.)

How did our system get like this in the first place?

It started with tax policy. During World War II, we had wage controls, but employer-paid benefits didn’t count. To attract employees, employers started offering more and more health benefits. This is our original sin. It could also be the font of redemption.

This led to dysfunction in what and how we pay. We’re sheltered from prices and focus on certain types of care.

Focus on sick care: Caregivers are typically only paid when patients need care, not to keep them from needing care (even though many are very good at this).

Opaque pricing: For lots of reasons, very few of us (including doctors and hospitals) know how much we pay for care or how much it costs to provide.

This has big consequences. Our system’s financial incentives aren’t aligned with the outcomes we want. 1) Overuse and overtreatment: Over decades, we’ve made millions of small decisions to increase use, which increases gain. 2) We undervalue what keeps us healthy: We allocate a tiny percentage of spending to many of the areas that help keep us healthy. 3) Plus, technology ends up hurting more than helping care: Health care is the only industry where technology results in higher costs and lower productivity.

This is what’s behind 50-plus years of hyper-inflation. Poor financial incentives + we all need care + decades = where we are today.

What are the easiest, most practical and most effective solutions you see? We know, this answer requires a book! But pick two or three.

1. Focus on high-cost claims, which take place with 6% of the employees but consume 80% of the spending. There are high rates of misdiagnosis and overtreatment, which lead to a tremendous amount of squandered spending and medical harm
2. Work with a benefits consultant who has full disclosure on their direct and indirect forms of compensation. We find that 95% of benefits brokers have significant conflicts of interest and lack of disclosure. For example, one  benefits consultant told me in one of his recent “clean ups” that the previous benefits broker had 17 undisclosed revenue streams
3. Invest in proper primary care. It both helps patients navigate complex conditions where they might be susceptible to over treatment and can provide prevention for avoidable conditions that can be a great cost down the road.

What’s next for U.S. health care? 

Washington political machinations focus far too much on rearranging the deck chairs on the health care Titanic. History shows us that all great societal challenges — whether they are civil rights, energy independence or better food — are solved bottom up. It’s on us to solve the problem. There is a growing DIY health reform that is restoring the American Dream one community at a time.

The great news is that all of the structural fixes to health care have been invented, proven and modestly scaled. The primary challenge is ensuring massive replication. Historically, dissemination of what works in health care has been horrifically slow. The institute I co-founded borrows from the open-source world, where information is disseminated much more rapidly to advance the state of the art.

What are the two or three most important things employees need to know about health care?

The fact that your employer is needlessly overspending on under-performing benefits packages is directly hitting your take-home pay. Other employers are spending 20-50% less with superior benefits packages.

As you pointed out in the chapter you contributed, in the “real” market (cash and direct pay), prices have been flat for over 5 years. In contrast, the rigged market that most employees experience has continued to have hyperinflation even though little of the underlying costs have truly grown (one exception is some pharmaceuticals).

What are the two or three most important things employers need to know about health care?

The best way to slash health care costs is to improve benefits. There’s no reason to submit to the tyranny of low expectations and simply expect a less bad rate increase. Not only is there a chance to lower health care costs, a proper benefits package includes behavioral health and physical therapy woven tightly into a modern primary care practice. That supports a high performance workforce and ensures people receive the proper, timely care.

Anything else we need to know?

Millennials are now the largest chunk of the workforce. The oldest millennials are leaving the invincible stage of their life and thus paying closer attention to health benefits. Those health benefits are designed as nearly a perfect polar opposite to what they want and value.

A smart benefits program establishes a 3-year transition plan from the old, under-performing benefits package to a high performance benefits program. Millennials and new employees are a perfect group to into the new “Tier 1” benefits package.

We all typically want what millennials want. They are simply the early adopters of better food, smart phones, social media, services such as Uber and more. Assuming you deploy a modern benefits program, millennials can be great evangelists to get the bulk of the rest of the employees on board over the 3-year transition period.

Informational source

A new report this week about future increases in Medicare spending set off wildly misleading headlines about the program’s future and what it might mean for efforts to expand it, as many prominent Democrats are proposing. As you wade through all this, there may be much less to the new forecast than meets the eye. Keep in mind three points:

• Medicare spending is projected to rise faster than private health insurance spending. But that mostly is because the number of people enrolled in Medicare is rising so much more rapidly.
• Medicare spending per enrollee is projected to grow at roughly the same rate as private insurance, after several years of growing more slowly. Thus, these new estimates say little about Medicare’s relative efficiency as a buyer of medical care.
• This is 10-year projection. And long-term forecasts of health expenditures are nearly always wrong.

The estimates, published in the journal Health Affairs, were produced by staffers at the Centers for Medicare and Medicaid Services (CMS). It is the latest report in an annual exercise aimed at projecting national health expenditures for the coming decade.

Overall, the CMS analysts projected that medical care will consume 19.4 percent of total US output in 2027, up from 17.9 percent in 2017. The annual rate of medical spending growth will exceed 5 percent by 2027, while other government estimates forecast the overall economy will grow by less than 2 percent.

One-fifth of GDP

Combined with costs of long-term supports and services, the US will be spending more than a fifth of its Gross Domestic Product on health and supportive services. That is noteworthy and worrisome.

While conservatives often warn about government taking over health care, that train already has left the station– at least if you are talking about who is paying. In 2018, Medicare and Medicaid alone paid for more than half of all medical care. By 2027, the two programs will pay about $2.5 trillion, or 57 percent of medical spending. And that doesn’t include other federal payers such as the military and the Veterans Administration.

Now, about Medicare: Overall, CMS estimates program spending will grow by an eye-popping 7.6 percent by 2027, far outpacing private health insurance that CMS thinks will grow by about 5.1 percent.

Aging Baby Boomers

Some spending growth will be due to higher costs for hospital care and prescription drugs. But private insurance also will be paying more for those service and products. Thus, per enrollee spending growth will be only slightly higher for Medicare than for private insurance. And other evidence suggests that Medicare spending growth for some common conditions, such as heart disease, may be slowing.

The main reason Medicare spending is projected to rise so much faster than private insurance is the huge gap in expected enrollment.

CMS figures that private health insurance will cover fewer people this year than last, largely because of efforts by the Trump Administration to discourage enrollment in the Affordable Care Act health exchanges. Enrollment will be growing again by 2027, but slowly.

By contrast, the aging Baby Boomers will drive significant growth in Medicare enrollment from about 59 million last year to more than 73 million in a decade.

Little evidence

To its credit, CMS looks back at the accuracy of its prior estimates. Not surprisingly, its   spending projections have been fairly close to the mark for three years out. But after that,   not so much. Enrollment in Medicare, driven largely by demographics, is easy to project. But a forecast also requires making assumptions about unknowable changes in technology, competition, and the law. For example, will the government lower the costs of prescription drugs? Will the US have Medicare for all? And what does that even mean?

The CMS forecast of future health spending is a valuable tool. It tells us that medical treatment will continue to absorb a growing share of our economy, which leaves fewer resources for other endeavors. And it tells us that aging Baby Boomers will drive a big increase in Medicare spending, though we knew that.

But it tells us very little about whether Medicare is a more or less efficient payer of health care than private insurance. Keep that in mind when politicians try to use it as evidence for their views on the future of the program.

Informational Source

Jill Ladkin was already having a terrible autumn. It began with a seizure that put her in the hospital with what seemed like scores of unfamiliar physicians attending to her state of health. The brain scan revealed a mass in the lining of her brain, a location usually signifying a benign tumor; but, given her seizure, the tumor was hardly what you would call a harmless growth. The surgeon had a theory of what was going on; the neurologist had a different theory. The resident, a trainee, was not even convinced that Ladkin’s seizure was a consequence of the tumor. But Ladkin’s primary care physician soon clarified the situation, telling the resident to stop speculating about some non-tumor potentially causing her seizures. “Occam’s razor,” he said, reminding the resident to never look for a second diagnosis when one diagnosis suffices. “She has a f#@$%’g brain tumor.”

That is the kind of doctor he was. Her primary care physician did not content himself with only her primary care needs, like checking her cholesterol and making sure she got her annual flu shot. Nor did he defer to specialists when she got seriously ill. Instead, he got right down into the thick of the details. There in the hospital, he settled by Ladkin’s side and helped her figure out what to do about her tumor. He looked over her scans, pulling up medical articles about seizure-causing meningiomas. Ladkin was used to such attention; he had been her primary care doctor for 15 years, never once making her feel like he did not have all day to address her needs. They debated the pros and cons of her treatment alternatives and settled on a course of therapy – surgery followed by radiation. He said he would follow up with her in his clinic, once she had recovered from the surgery.

That is when Ladkin’s autumn got even worse. After she left the hospital, she called into the office to confirm a follow-up appointment with her primary care doctor and learned that he no longer worked at that office. He disappeared, retiring from medical practice for reasons Ladkin never discovered.

In the middle of treatment for a brain tumor, she had to find herself a new physician, discovering just how difficult it can be for people in the United States to get timely access to primary care.

Access. It is one of the “triple aims” that health policy experts evaluate when studying healthcare systems, alongside cost and quality. A well-designed healthcare system should provide people with ready access to medical care when they need it, care that is of high quality at an affordable cost. If you want to brag about your country’s healthcare system, you should be able to point to how easy it is for people to access medical care. Sadly, the US has never had much to brag about when it comes to access. We lead the developed world in the percent of people without healthcare insurance. Even worse, as Ladkin learned, having insurance is not the same as having ready access to medical care.

Not long after calling the primary care office, Ladkin received a letter from her insurance company informing her that her doctor would “no longer be in your Blue Choice network starting 2-15-2016.” (The letter was dated 2-25 and arrived 2-27). The letter went on to note that if her previous primary care physician had made any sub-specialty referrals, those would no longer be valid. “Tell us the name of the doctor you choose within 30 days,” the letter continued. “If you do not choose a new doctor, we will choose one for you.”

Ladkin knew that she better get to work. So she looked at the list of in-network primary care physicians that her insurance plan had sent, only to discover that the list was disturbingly out of date. Undaunted, she called the internal medicine practice where her physician worked. “Do you have other internists who could take me on as a patient?,” she asked. She was told that no official primary care assignment could be made until they had an appointment with one of the alternative providers, none of whom could see her for for at least 30 days, the time at which the insurance company said it would assign her a new primary care physician at another location.

She continued to scramble for information. “Is there another doctor joining the practice who will replace my previous physician?”  No. “Will someone at your office renew prescriptions I’ve been receiving from my primary care physician?” Yes, but only for two months. Ladkin hung up the phone and called a dozen physician offices, looking for a doctor willing to assume her care. “The insurance company list of available providers was basically useless. The providers either were not available – were not taking new patients – or they were not even primary care physicians.” She was zero for 12: “I felt very fragile, like I was going on dates and being rejected.”

If you are not yet established in a primary care practice in the US, you better get started now. Because even if you develop a relatively urgent need for medical care, you could have a very difficult time finding a physician who will see you in a timely manner. Finding a primary care physician can be difficult for a whole host of reasons. For starters, some people in the US do not have healthcare insurance–they might live in a state that didn’t expand Medicaid, for example, because the government did not want to be seen as supporting Obamacare; or they might be undocumented immigrants who do not qualify for government subsidized insurance; or they might have decided to pay a tax penalty rather than purchase health care insurance. It is hard to get an appointment with a physician if you can not pay for her services.

But some people have a hard time finding a primary care physician even when they have insurance. That’s certainly what Simon Haeder from West Virginia University discovered when he and colleagues conducted a secret shopper study in California. Haeder was concerned that people buying healthcare insurance through the Obamacare exchanges might face a particularly difficult time getting medical appointments, because so many exchange plans use narrow networks of providers to keep costs down. (A narrow network plan has a relatively small number of local providers who take that insurance plan as full or near-full payment for their services.)

Haeder discovered that people with Obamacare plans were just as successful making appointments as people with more traditional insurance plans. Let me rephrase that. People on the Obamacare exchanges were just as unsuccessful as people with traditional insurance – 70% of the time, Haeder’s secret shoppers were unable to get an appointment to see a primary care physician. Even when they told the appointment clerks that they had symptoms that suggested the need for urgent evaluation, complaints like heavy menstrual bleeding or high fever. Worse yet, when Haeder’s team could not get timely appointments, they often were not told to seek care elsewhere, such as at minute clinics or urgent care centers.

Why is it so difficult for Americans to make doctors’ appointments?

For starters, physician directories are often inaccurate. In 10% of Haeder’s secret shopping efforts, physicians were not at the office locations or phone numbers listed in the directories provided by the insurance companies. In another 30%, the directories misstated the physician’s specialty. Women calling what they have been told are family medicine offices should not find themselves talking to ENT clerks about heavy menstrual bleeding.

To make matters worse, if you find a physician correctly listed in your insurance company’s directory, and one who actually accepts your insurance plan, you might discover that she is not taking new patients or does not have an opening for a new patient for another six months.

Before you complain about too many Americans going to urgent care centers or emergency rooms for non-emergent problems, remember that, if people are not already established with primary care physicians, they might have real trouble getting timely care for important problems.

Ladkin finally struck upon a solution to her primary care problem. While she called yet another physician’s office, she spoke with an appointment clerk who told her that the doctor was not seeing new patients. Ladkin began crying. The clerk tried to soothe her, but Ladkin pleaded: “I have a brain tumor,” she said, “can you help?” The clerk put her on hold. A few minutes later, she told Ladkin that the doctor would squeeze her in that week.

It should not take a crying jag for an American to get a timely medical appointment.
Do you want to know more details about the health insurance in pa and personal finance management then please drop your comments in the comment section.

Informational Source