Posts tagged managed care

Sign the petition to Congress: We won't go back!

But the President’s concession is still dangerous because it opens the door for Republicans to argue that people ought to be able to choose whatever health insurance policy they want — next year and beyond. Not only would this undermine the minimum standards in the Act. It would also enable healthier people to leave those who are sicker or with pre-existing health problems behind in the new federal system. The obvious result would be to drive up premiums and costs of the federal system so high it couldn’t be maintained. Remember: The Act requires insurance companies to take people with pre-existing conditions and bars them from dropping policies of people who become seriously ill. Republicans have never supported this. They apparently don’t give a damn about these people, and don’t want healthier and younger people to have to subsidize them. They prefer social Darwinism, survival of the fittest.
Dr. Robert Reich on The White House tinkering with the Affordable Care Act

A snippet from the text of the story.

There are also deductibles — the amount you pay up front, before your coverage fully kicks in.

And there are co-pays — the $20 or $30 payments you have each time you see the doctor — provided, of course, the one you need is in your network. Many of the policies could have fairly limited networks of providers and hospitals.

The insurance market under Obamacare, in other words, is supposed to be a friendlier one than what exists right now. And that’s what Trader Joe’s seems to be betting on with its move: that its workers will see similar options without the grocery store footing the full bill.

Whether this will be true is hard to game out at this point. The Huffington Post did talk to one Trader Joe’s worker who estimated that she earned about $20,000 and currently pays $70 a month for a pretty robust health plan. Trader Joe’s plans to kick in $500 for each employee, or about $40 per month. So we’re looking at a total of $110 to spend on the marketplace each month, if spending holds to the same level as what Trader Joe’s workers pay right now.

The rate data we have so far (largely from the Kaiser Family Foundation) suggest that comparable premiums will be available for someone earning $20,000. Using a calculator that Kaiser helped build, it shows that a 25-year-old who makes that much here in the District would pay $85 for a middle-of-the-road plan and $26 for the bare-bones option. Premiums are a bit higher for those who are older, and a little lower for younger subscribers.

As for what Trader Joe’s decision means for the health-care law, that’s not totally clear either. On the one hand, it likely makes the health law more expensive: Trader Joe’s is essentially shifting the costs it used to pay for health insurance onto the federal government. On the other, bigger marketplaces are good for the health law. More subscribers make it more likely that insurers will want to sell and, if Trader Joes’ employees tend to be younger, they’ll likely help hold down the cost of premiums there

What Americans’ annual health care spending could buy. 


What Americans’ annual health care spending could buy

Health Insurance Reform That's Not Good Enough for Nathan Fletcher

What kind of laws about managed care providers doesn’t Nathan Fletcher like? Laws that:

…prohibits health care service plans and health insurers from implementing a rate for a new product or instituting a rate change unless it submits an application to the Department of Managed Health Care (DMHC) or the Department of Insurance and the application is approved. The Director of DMHC and the Insurance Commissioner would have the authority approve, deny, or modify any proposed rate or rate change.

Click the banner headline more if you want to know how Fletcher voted. Remember the last time you got jerked around by your health insuror, then remember Fletcher’s vote in the assembly when you vote for Mayor.

Jay Parkinson + MD + MPH = a doctor in NYC: Why is making healthcare easy so hard?


Well, the simple answer is there are too many players and partnerships between them are next to impossible to broker. In order to fix the healthcare experience we all hate, the partners must have a singular vision for a better experience, and then broker the deal so we all benefit.

There are a…

C’mon Jay…just say it, time has come for a bad idea: we need a single payer system.

CBO: Medicare’s demonstration projects fail to demonstrate cost savings

… imagine a system in which all payments are negotiated, as with a single payer system. Hospitals negotiate an annual global budget. That budget includes their costs of services, such as coronary bypass surgeries, without the need to itemize each single item for the services, nor the need to bundle payments in some sort of pretense that global costs are reduced. The hospital already has incentives to improve efficiencies to stay within budget.

Likewise, physicians collectively negotiate their payments, whether fee-for-service, capitation, or salary, as appropriate to their clinical circumstances. Payments are adequate to ensure a very comfortable net income.

Other nations have proven that negotiated, administered payment is effective in obtaining greater value for health care spending. We’ve now proven that intrusion of market-model games players such as outside disease managers, or pay-for-performance administrators, have failed to improve value. So we should go with a system that really does work – a single payer national health program.

Insurers: Trust us on risk adjustment

Now the insurers want to do their own “distributed model” of risk adjustment, preventing federal or state bureaucrats from looking over their shoulders as they do their dirty deeds. This applies not only to Medicare Advantage plans but to all plans in and out of the exchanges, except for grandfathered plans. They claim that this secrecy is necessary to maintain patient privacy and to protect the insurers’ proprietary data, but risk adjustment of the Medicare Advantage program has demonstrated that these are not valid concerns.

Risk adjustment does not work, as the insurers will always game the system. The insurers’ solution is to allow them to do it in greater secrecy, with a “trust us” attitude that certainly has not been earned based on their previous behavior.

PNHP response to Rick Ungar’s “Obamacare Bomb”

Limiting overhead to 15%-20% is far from the stringent regulation that Ungar implies. Private insurers’ overhead currently averages about 14% nationwide, and they will probably be able to reclassify some items currently classified as overhead into the patient care expense category (despite regulations that attempt to stop this). Moreover, some current sales expenses will be offloaded to the insurance exchanges, which are likely to have overhead of 3-4%, and the exchanges’ expenses will not count as part of insurers’ overhead. Finally, ACOs will take over many of insurers’ administrative tasks and expenses, but these ACO overhead expenditures will not count toward the 15%-20% overhead limit. In sum, total insurance overhead (and profit) is likely to grow, not fall in the years ahead.