Debates continue about the impact of health reform on small businesses. Mine is a small business so I’ve been paying close attention. I’ve even read every line of this legislation – three times. And every pundit analysis I can get my hands on.

My role as a strategist requires that I understand the law. My role as a business owner requires that as well. Most analyses make broad-brush statements and it’s not possible to know the full impact until each business does its own analysis. Here’s mine.

Unfortunately, there are no ‘upsides’ for my employees or business:

• My company is too small to be required to provide health insurance. That’s of no matter, I’ve been providing it all along.
• My company is unlikely to grow to the size required to provide health insurance. That’s of no matter, I’d do it anyway. As an employer I know the value of a healthy workforce.
• My company is too busy to even consider applying for grant funds for worksite health promotion and disease prevention. We’d lose productive work hours watching for RFPs, framing proposals and even more complying with paperwork. That’s of no matter, I’ve been providing that all along as well.
• My company is composed of workers too highly compensated to qualify for insurance tax credits, and I suspect no company like mine will qualify either. My employees are knowledge workers with advanced degrees and compensation above the $50,000 annual ceiling for the tax credit provisions.

Unfortunately  there are ‘downsides’ for my business, all related to new IRS rules.

Section 9006 mandates that about 18 months from now, my business – which really means my Executive Assistant, who is already plenty overloaded – will be required to issue 1099 tax forms to any individual or company from which we buy more than $600 in goods and services.   

We already issue an IRS Form 1099 to people like freelancers who are not ‘incorporated’ business entities. In any given year, that number ranges from 10-14.

That means we don’t send a 1099 to other incorporated businesses, that is, to Amazon, Amtrak, US Airways, Continental Airways, British Airways, Air France, Westin Hotels, Marriott Hotels, Holiday Inns, Kinko’s, Federal Express, Staples, Office Supply, Office Doctor, IT Edge, Samsung, Independence Blue Cross…I could go on.  

This new 1099 reporting is intended to capture currently unreported income to generate more government revenue and help offset the cost of reform. It’s been defended as an alternative to raising taxes on small business and is seen to be a fair trade for $35 billion in tax credits small businesses get under reform. It’s an attempt to collect the nearly $300 billion of income that the IRS says goes unreported.

I have three problems with that:

• First, my business won’t see any of that tax credit benefit, 
• Second, my business will incur additional costs, not only in staff time for obtaining tax IDs from every vendor, but also in accountant fees for processing and mailing the forms, and
• Third, my business is being required to help the IRS monitor tax reporting compliance of other businesses.

At this point, we estimate the number of 1099s we will file will increase to 1,000. I’m not sure how a small firm like mine is going to find its way through the mazes of large companies to get the information, but I’m angry that this law – touted as having so many ‘upsides’ – provides none for my firm but asks us to carry an additional burden that drives up the cost of doing business.

I can live without the ‘upsides.’ I’ve provided insurance and promoted wellness all along and will continue to do so.

But now, I’ve been mandated to become a de facto agent of IRS enforcement. Surely, the IRS has better tools for finding unreported income than asking small firms like mine to do it for them.

By Lisa Korin. The media has given much attention to the health insurance aspects of health reform, but less to aspects of the law addressing the root issues.  Yes, the number of uninsured is a huge problem, but let’s not forget that an increasingly chronically ill population needing access to often expensive health services is one the key drivers contributing to the plight of the uninsured even needing insurance.

According to the CDC, nearly 50% of the U.S. population suffers from a preventable chronic health condition, and these diseases account for 75% of the nation’s $2 trillion annual healthcare costs. Much of these costs arise from:  patients obtaining care from multiple healthcare providers, lack of medical care coordination, duplicate diagnostic testing and provider visits, and treatment non-compliance due to consumer confusion.  These facts indicate that increased spending on chronic conditions does not necessarily result in better health outcomes and means that patients with chronic conditions currently receive health care in a manner that may not be the most cost-effective.  These statistics are even more pronounced for minority adults and children as well as for those with low incomes, for whom there are greater disparities in access to care and treatment plan compliance.

That’s why I was glad to hear that H.R. 3590 Patient Protection and Affordable Care Act had provisions related to the patient centered medical home (PCMH) model of care.   According to the Patient Centered Primary Care Collaborative, PCMH is an approach to providing comprehensive primary care to adults, youth and children that broaden access to primary care while enhancing care coordination. Clinicians practicing in the highest level medical home will: (more…)

By Phyllis Kritek. When I hear a story repeated in different parts of the country by persons who differ, one from another, in striking ways, I pay attention: This is no longer a story, it is a pattern. The stories preoccupying me these days are ones where parents of recent college graduates tell me that their son or daughter successfully completed college but was unable to find a job, and thus became a waitperson, the politically correct term for one who serves food in a restaurant. Usually waitpersons do not have health care coverage through their employer.  We can find these same young people in the health care insurance reform legislation: they can now stay covered by their parents’ insurance policies until the age of 26. I think this is supposed to be good news.

Watching the unfolding drama of the health care insurance reform legislative process and the citizen responses, I kept looking for the young people. They were virtually invisible, perhaps busy serving food, and their unique plight went unexplored by virtually everyone. I wondered if their concerns were embedded in the endless polls, or even if they were being polled. The mandate for individual coverage, it is anticipated, will uniquely burden these young people. The anticipated challenge of a rapidly expanding aging population with extensive health care needs is their responsibility to assume, we assume.

As a group that has been fairly well researched, the baby boomers have some descriptors they do not like, no matter what the evidence. Along with a whole raft of wonderful qualities, it is often noted that they are self-centered and self-absorbed. They tend to reject this descriptor out of hand. Their elders, in the early studies on generational characteristics, were interestingly not called the “greatest generation” but the “entitlement generation”.  I watched Tom Brokaw’s recent report on the boomers, waiting for him to ask a young person what he or she thought about the boomers. It did not happen. I watched the obsessive air time given to angry, often vitriolic people reacting to the impending health care legislation: none of them looked very young to me.

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By Santi Bhagat, MD, MPH. Health Care Reform is off to a good start.  A couple of days ago, I blogged on the debate between the insurance industry and the administration about the interpretation of this new law.  Hats off to insurers for making the right choice, right away, to heed regulations that are forthcoming from Health and Human Services.   I first heard this through the grapevine at the Disruptive Women Breakfast Series this week from Stephanie Cohen, the expert panelist representing the insurance industry.

The law is intended to require insurers to issue policies that provide a full range of benefits for all children with pre-existing conditions starting in September 2010.  That means insurers can no longer refuse to cover children with pre-existing conditions under their parents’ plans, even if the children never had insurance.

This law has far-reaching ramifications.  A recent story about a newborn who was denied coverage at the age of a mere 9 days highlights how critical this law is.   Born with a congenital heart defect, Houston Tracy underwent lifesaving open heart surgery when he was just 4 days old.  His parents cannot afford insurance for themselves, being small business owners, and have individual policies for their older two sons.  After being charged and given the run-around by the insurance company, they resorted to enrolling their newborn in the state’s high-risk pool.

The big question now is how much will insurers charge for these policies.  If the price tag is too high, parents will not be able to afford to purchase policies, and in effect, coverage will be denied to these children.

It is not clear whether HHS regulations will speak to this issue.  The administration will be watching the insurance industry closely.   So will we.

Hygeia Note:  On March 30th, Disruptive Women in Health Care launches the first of its monthly in-person breakfasts.  Among our speakers will be Stephanie Cohen.  Her post appears below.

By Stephanie Cohen.  This month’s health insurance nightmare: Dad is still paying for his daughter’s insurance — and no one is happy.

The situation: I received a call last week from a client whose daughter recently told him she hates her insurance “because it does not cover anything.” He phoned me to see if she had a real gripe, and if I could help him find another policy with better coverage for her.

The problem: It turned out that her policy had a $5000 deductible, which did not include coverage for dental or vision doctor visits. Since she has an entry-level position and not a lot of extra spending money, I told her she had a choice.

She could choose to pay more per month to lower her out-of-pocket expenses, but her monthly premiums would be higher. Since her father was paying her premium, and was happy to do so, I decided the best policy for her was one with a higher premium and lower expenses.

The solution: The decision to pay for an adult child’s health care is a personal one that each family must make, of course. The reality is that once a child turns an age selected on the policy by the plan administrator based on the rules of the state and the size of the employer, they are no longer considered a dependent.

Many times, the insurance company does not notify the parent or the plan administrator that the student has been dropped. The student typically finds out when filling a prescription or when receiving services. 

Keep in mind that it is the parents’ responsibility to notify the carrier that the student is or is not a full-time student and is eligible for coverage. The student is responsible for having a student certification form completed and signed by the bursars office proving they are in school fulltime with 12 plus credits.

If I were the Health Insurance Ambassadors: All students would have to prove they had coverage or they could not attend school.

Although with the recent health reform legislation there is now a new Federal mandate to allow children to be on their parents health plan until 26, it still may be less expensive to insure that child unto themselves rather than remain on the parents plan.  Obviously, the rates will be much lower for someone who is much younger.

The painful truth: Parents can analyze the cost of coverage through the school or an individual policy versus the cost of keeping the child on his/her plan. If the parent has other children on the plan, it rarely saves to pull one child off the plan.

 I encourage you to share your insurance nightmares with me.

By Santi Bhagat, MD, MPH.  Policymakers and insurance industry are battling over a key feature of health care reform.  As the president proclaims the bill will cover and protect all children with pre-existing conditions this year, the insurance industry is contending that the law reads differently.   

Congressional leaders are outraged that insurers are trying to wriggle out of their legal responsibility to insure new children who have pre-existing conditions. 

1. Insurers are interpreting bill language to mandate coverage of pre-existing conditions of children only if they are currently enrolled in plans, but not for new, uninsured child customers with pre-existing conditions. 
2.  The administration vows to fix this by having Health and Human Services (HHS) issue regulations next month to clarify the law’s intent to both provide access to insurance and a full range of benefits for all children with chronic conditions this year. 
3. Insurers plan to act on legislation language.  They will not say how they will respond to regulations and forecast that the courts will be the final arbiters.
4.  HHS spokesman and chairmen of Congressional health policy committees in the House of Representatives assert that the administration’s solution adequately addresses this problem.  
5. Citing experiences in other states, insurers are saying that covering children with chronic conditions now will lead to higher rates that may be unaffordable.  They believe that it is better to wait until 2014, when the risk can be spread since most Americans will have to be covered that year.
6. Regardless, insurers are free to charge what they want until 2014, when health status can no longer be used to calculate premiums. 

This is no small matter, for one in five American households, 8.8 million, has at least one child with a pre-existing condition.  Contrary to popular thought, most of these children are covered by private insurance.  The economic and job crises have impacted the ability of parents to maintain employer-based health insurance, forcing them to turn to the exorbitant individual market.  Children with individual coverage and who go without insurance for two months are at the greatest risk of being denied access.  From September 2010, the health care bill is supposed to prohibit insurers from denying individual and group coverage to children based on health status.

Health care reform does provide for a $5 billion dollar insurance pool of last resort that these families can turn to.   Hopefully, this mechanism will help families until this problem is straightened out.

Parents cannot wait to obtain coverage for their children who are in urgent of need of health care now.   Children are not simply little adults:  denying access and care to chronically ill children denies them the ability to grow, develop, play and learn.  As we watch the deliberations and wait for implementation of this piece of law, our children and families are losing precious time that can never be recovered.

By Stephanie Cohen. This month’s health insurance nightmare: You believe the cost of your policy is too high and the benefits too low.

The situation: Sara E. was looking at new insurance options because she was concerned that her current policy cost too much and covered too little. A case in point was a recent eye exam. She had to pay for the appointment because she hadn’t yet met the $1000 deductible on her current policy.

The solution: It was clear that Sara did not understand the details of the policy she had purchased. It’s not unusual, but can prove problematic. In fact, we recommend that all of our customers make a list of the medical services they will likely need throughout the year. Before buying anything, we tell them to read the fine print on the policy and ask questions until they are certain they understand what they are paying for – and what will be an additional charge.

Here’s why: The fine print on an insurance policy can be complex. The bottom line is that if you purchase a policy with a high deductible, there will be no coverage until the deductible is paid in full. Deductibles apply to all coverage if you purchase an HSA (Health Savings Account) compatible plan – except for preventative services.

And realize this:

1. Deductibles can also apply to specific services such as lab work and hospitalization.

2. They also apply to services differently depending on whether they are in or out of network.

3. It’s important to know that deductibles may be cumulative or shared, or based on the calendar year or contract year. Know how it works for the policy you purchase.

4. If the policy is a Health Savings Account (HSA) versus a high-deductible plan, you will be able to write off the amount placed in the HSA account up to the maximum allowable by the government. The minimum deductible for HSA plans start at $1200 for a single and $2400 for a family.

5. Do note that there are many after-tax expenditures such as those that are included in the FSA Section 213 of the tax code, which can be written off that are not covered under an insurance policy, which is the advantage of an HSA.

If we were the Health Insurance Ambassadors

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Every January, new billing rules and rates go into place for physicians’ services as part of the annual update to Medicare’s Physician Fee Schedule. Dominating DC health policy concerns in this arena are the medical community’s efforts with Congress to address Medicare’s cost-of-living adjuster, known as the “sustainable growth rate” (SGR), which would have lowered 2010 fees across-the-board by 21 percent, if not for a last-minute temporary stay through the end of February. Negotiations with Congress are on-going to provide a long term or multi-year solution—a costly “fix” that I believe is well worth the price to keep physicians in the Medicare program, and seems to have widespread support.

Getting much less attention is a unilateral policy pronouncement made by the Centers for Medicare and Medicaid (CMS) that Medicare will no longer pay specialists a higher rate for consultations—services often provided by specialists like cardiologists and neurologists. Instead, all physician visit services, whether defined as “evaluation and management” (E&M) services or consultations, will be reimbursed at the same E&M rates. (more…)

Healthcare (insurance) reform has passed in the Senate and final negotiations are happening before it moves on to the President’s desk for signature. While the legislation is not perfect – in fact some would say far from perfect – it is a piece of legislation that is very much in keeping with our American philosophy, our constant pursuit of progress and change.

As the late Senator Kennedy’s career on Capitol Hill demonstrated, change is usually incremental, usually negotiated and usually compromised. But at the end of the day, change usually amounts to progress.

I see tremendous progress, too, as I look back on a decade’s worth of work to promote access to affordable quality health care using nurse practitioners in the role as primary care providers, thereby alleviating the burden on a strained primary care system.

We’ve come a long way regionally and nationally. The fact that we as a country are always striving to improve our path is what most invigorates me as a relatively new American. Our pursuit of progress is never ending, but it is what sets us apart from most countries in the world. We know our work is never done. As we enter a new year and decade, we always should remember that what makes us different from most people and countries in the world is that we have the freedom to purse progress and make change.

This health insurance reform bill is not the end all or be all, but it will help make affordable health insurance available to more than 30 million Americans who have been without it. Furthermore, the legislation contains many provisions for others who fall through the cracks and will need additional care and support.

That’s progress for individuals, families and America, as Walt Disney would have said. And not until you take a ride on the Magic Kingdom’s The Wheel of Progress will you truly appreciate how important it can be to take even a small step in the right direction.

Happy New Year! And a toast to a New Decade and our new Pursuits of Progress for individuals, families, and our country.

Healthy New Year everyone!

Like many people I’m starting the year with healthy – and preventive care – intentions. How about you?

That put a few items on my holiday ‘to do’ list:

• Get a pap smear,
• Find H1N1 vaccine,
• Wrestle the results of a recent bone density scan (Dexa) out of the hands of the medical center and into the hands of my physician, and
• Confirm with Morris White, my trainer, that I’d continue workouts.

The pap smear was easy – this time. I’d not been able to get one during my late-summer vacation visit to the doctor because the appointment was two weeks prior to the annual date of the prior test. That required another trip. Holiday downtime was a good time to do that. Check that off the list.

In doing so, I finally found an H1N1 vaccine dose! Getting a seasonal flu shot was easy at www.phillyflushots.com, but even after calling several immunization providers and both of my physicians at least twice monthly since H1N1 became available, checking websites and following news reports of shots at pharmacies – well, no success. Luckily, my doctor had just received a few doses of H1N1 that day of the pap smear. Check that off the list.

Results of a bone density scan months ago had still not shown up at my doctor’s office. Holiday time was a good time to badger for the ‘results,’ though it was hardly worth the trouble. Turns out  my physician is not part of that medical center’s ‘network’ and can’t get detailed results. Only a note: ‘normal.’ Sorry, that’s not good enough. Neither my physician nor I know whether there has been any change in bone mass since prior tests. Sure, the test results might be ‘normal,’ but the measures might also be trending in a direction that means I’m losing bone mass, something we both should know about. No check there, still on my list.

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Think you have maternity coverage? Think again.

Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because I think Disruptive Women readers will find it useful, each month I’ll post an example of a health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.

My goal, however, is to find a way to improve health insurance for beneficiaries and I have some suggestions at the end of this post.

This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation: When our client, Ms. R, found out a few years ago that she was having a baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits. Making the call was merely a formality. When she originally purchased the policy, she was single and didn’t opt for the maternity rider. After she got married, she added maternity coverage because she wanted a family.

Indeed, when she called the insurance company, they confirmed she had the insurance she needed. However, after her first OB check-up she received a letter saying she was, in fact, not covered.

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In the face of acute primary care physician shortages and steady reductions in the number of physicians who are willing to accept Medicaid and Medicare, it is unclear whether our existing primary care system will be able to meet the needs of a universally-insured nation, as President Obama has expressed as a priority for his Administration.

Health care delivery is strained under tremendous pressure from the demands of chronic health issues, downward trends in third party payments, and while insurance coverage will address some of these issues, many of these problems may persist even if universal insurance coverage is achieved in the United States. So what else needs to happen to make healthcare reform a success?

In recent years, a series of “disruptive innovations” in the health care sector have capitalized on non-physician providers, such as nurse practitioners, and their ability to provide high-quality primary and preventive care in retail-based settings such as Convenient Care Clinics (also known as retail-based clinics) and in community-settings, such as Nurse-Managed Health Centers. Research in Health Affairs and other peer-reviewed journals has documented that retail based clinics and Nurse-Managed Health Centers provide safe, accessible, affordable care to millions of Americans without threatening continuity of care. Nurse practitioners practicing in these independent settings already touch millions of people annually. Thanks to regulatory reforms that have taken place over decades, including those led by governors in Pennsylvania and Massachusetts, nurse practitioners are legally authorized to prescribe medications and provide care that is a comparable in scope to that of a primary care physician in all 50 states.

Consumers gravitate to both models because they are accessible, affordable, provide quality care but most importantly, they are convenient in their locations, hours and ease of use. For healthcare reform to be successful, we need to embrace these disruptive innovations. We also need to maximize the amazing, high-quality provider workforce we educate in our finest academic institutions across the country. Nurse practitioners and other non-physician providers (such as physician assistants, pharmacists, and psychologists) are eager to partner with their physician colleagues to expand access to care for all Americans and make the Administration’s healthcare reform effort the success it needs to be!

The U.S. Preventive Services Task Force unleashed a tsunami this week with new breast cancer guidelines that are suspiciously timed to current efforts to rein in burgeoning healthcare costs. Indeed, the recommendations appear to be geared towards reducing overtreatment by eliminating what the Task Force considers unnecessary follow up screenings and tests. The recommendations even suggest the breast self-examination (BSE) should be discontinued.

In essence, what the Task Force concluded was that while screening reduces deaths from breast cancer, it does not save enough lives to justify associated costs.

To exacerbate the controversy, the American Cancer Society has publicly stated that it does not endorse Task Force recommendations and in a detailed analysis suggested that in the review of the evidence, the committee got caught up in semantics (i.e. risk versus benefit) and that at the very least, computer modeling may be flawed in terms of its ability to translate statistical data into real life.

Meanwhile, the New York Times reports that many doctors are ‘staying the course,’ and in between anger and disbelief, women across the nation are crowding the phone lines trying to discern what is true and what’s not.

Have we all gone mad?

Obviously, these new recommendations will be echoing in the halls of hearings that will determine the future role of mammography in government-run health programs, private insurance programs and the current healthcare reform initiative. Already, Congress is calling for Hearings. But more importantly, is the debacle is a prime example of what ails our healthcare system and reflective some of the more important changes that must take place if we are ever going to move forward in a way that benefits all the players. Truly, who’s really in the driver’s seat?

The fact is that although nearly 250 million Americans do have health insurance, according to a monthly survey of about 50,000 households done by the Bureau of Labor Statistics and the Census Bureau, an estimated 46 million Americans do not.

Listed below you’ll find arguments for not having health insurance that I hear on a regular basis. As a broker, I’ve provided a reality check for individuals to consider before making their final decision.

1. It costs too much.

The reality: Should a catastrophic illness or injury occur, it would likely bankrupt most people who do not have health insurance. It’s the terrible fact of life in 2009. Medical care is incredibly expensive, and employers are increasingly less likely to be able to support an injured or ill employee. So if something happens to you, and you have not saved enough money to support yourself if you are unable to work, odds are good that you will be in debt for astronomic health care bills and, unfortunately, many of us would be hard pressed to ever climb out of that financial hole. Don’t be scared. Just think long and hard about that.

2. It does not cover all of the health care needs that I have now, or might have in the future

The reality: The truth of the matter is that a good health insurance broker can usually find a policy that covers most every medical problem that is likely to arise. There are also resources that can be used to supplement your plan. For instance, if you need discount drugs, it is possible to fill your prescription at Wal-Mart or in Canada. Need a flu shot? You can get one at your local pharmacy. My mother always told me, “where there is a will, there is a way.” I believe that to my core. You just need to be clever and work at solving your own problems.

3. The drug benefit is insufficient on most health care plans.

The reality: See above. And do remember, you are your own best health care advocate. The health insurance plans cover many things, but you need to do some legwork to get everything you want and need for your own care.

4. The process of finding the right health insurance is too complicated.

The reality: Honestly, it really is not. Think about the old adage — “How do you eat an elephant? One bite at a time.” The same applies to health insurance. People think that the process of understanding a policy is just too difficult, so they tend to shut down before they even try to take the time to comprehend it. Don’t give up too soon.

5. I have a specific health issue that was not covered satisfactorily in the past, so I’m not inclined to buy health insurance again.

The reality: Please realize that not all policies are the same. There is definitely one that is right for each individual. Plus, there are often state-run programs that can address most insurance needs. If you had an issue it is likely that someone else did too, so take solace in the fact that you are not alone.

6. I am healthy and do not need health insurance today.

The reality: That’s true. Until, of course, you do need it. You will. You are human. Humans get sick and often need to see a doctor. So please, do not be stupid. Protect yourself against what is more than likely to come. In the case of a catastrophic incident, this ignorant assumption cannot be undone.

7. Obama will help me get free insurance.

The reality: I cannot believe how many times I have heard this in the last few months. I am the first to admit that President Obama is doing his best, but please stay grounded in the facts. The U.S. government is not going to give everyone a free health insurance policy. Unless you are very poor, forget this as an option. Take care of yourself today and buy an affordable health insurance policy.

8. I want to wait until health insurance is cheaper.

Having been in this industry for more than two decades I can speak from experience that health insurance companies are not in business to help you. Insurance is not going to get any cheaper — at least, not any time soon. It is heretic to admit, but insurance companies do not make billions for their shareholders by helping the little guy. We are easy targets. We have no lobbying power, and they know it.

The bottom line: Be smart. Buy a health insurance policy that will at least cover you in case of a catastrophic event. Health Savings Plans are a good option, and more solutions are coming on the market. The bottom line is that if you take care of yourself, you won’t regret it.