• A year after President Obama signed health reform into law, the public remains deeply divided over the landmark legislation, with a year of political debate over its merits and the beginning stages of its implementation doing little to alter Americans’ opinions about the law. In March, one year after enactment, 42 percent of Americans hold favorable views of the law while 46 percent view it unfavorably, a basic division that has changed little during the last 12 months. (In April 2010, 46 percent had favorable views and 40 percent unfavorable ones, but both figures have ticked up and down over the last year.) Opinion of the law continues to break sharply along partisan lines, with 71 percent of Democrats backing the law and 82 percent of Republicans opposing it.

• About half (51%) of Americans who like the law cite expanded access to insurance and health care as the reason. Those who do not like it give a greater variety reasons: 20 percent are concerned about costs; 19 percent have concerns about government’s role; and 18 percent mention opposition to the individual mandate.

• A majority of Americans do agree on something: 53 percent are confused about the law, the major provisions of which won’t take effect until 2014. This is nearly identical to the 55 percent who reported being confused in April 2010. Further, 52 percent this month say they do not have enough information about health reform to understand how it will impact them personally, while 47 percent think they do. Members of the groups most likely to benefit from health reform — the uninsured and those living in low-income households — are the most likely to say they do not know enough about the law’s potential impacts. (more…)

By Hope Ditto. It’s still too early to tell what exactly will come of the repeal vote on the Hill this week, and what it will mean for health care coverage. Whether the law is repealed altogether, or whether supplemental bills changing different parts of the original legislation are passed, only time will tell. Whether Obama will veto the repeal act, should a repeal make it to his desk (okay, that’s pretty certain, but stranger things have happened), or whether the Republicans would be able to whip enough votes for an override, we can only venture guesses. Only one thing is for certain – there has never been a more confusing time to buy health insurance.

That’s where health care benefits consultants – like Disruptive Women blogger and Golden & Cohen benefits consulting firm co-founder Stephanie Cohen — come in the picture. Cohen is an expert in the field of health insurance and familiar with all of the changes being implemented (no easy feat). Along with the other consultants at her firm, Cohen helps to find the best possible coverage for individuals and groups (insurance world speak for families and companies), taking into account each entity’s specific needs and financial situations.

I recently had the opportunity to sit down with Stephanie and ask her about all things health care – including her tips for choosing a health insurance plan. Here’s what she had to say.

Question (Q): Why does a person or a company seek out a benefits consultant as opposed to just securing their own health insurance?

Stephanie Cohen (SC): A benefits consultant is an expert in health insurance; most people are not. Purchasing a health insurance policy is like preparing your tax returns; what one puts together for his or herself may be very different from the next person based on many variables both known and not known. Only an expert, who understands all the questions to be asked, can determine the appropriate policy that will yield the greatest return. Health insurance matters so much; why would you risk making a bad decision based on your own inexperience?

Q: Obviously when you say health care these days, one topic and only one topic comes to mind – health care reform (and subsequently, recent attempts to repeal it). In what way will the final decision on the Hill regarding repeal impact your work?

SC: Uncertainty begs for good consultation. The more things are in flux, the more consultants are needed.

Q: Speaking of health care reform and the happenings on the Hill of late, how would you explain the pros and cons of the Affordable Care Act to someone less familiar with the health care/health insurance industry?

As with anything, there are pros and cons to the Affordable Care Act, and its repeal. On the one hand, it allows people with pre-existing conditions to get coverage at reasonable (or at least comparable) rates, it allows dependents to stay on their parents’ plan until the age of 26 and it eliminates co-pays on routine physicals. But, it is driving the cost of all insurance up, it is not friendly to business, it won’t bend the cost curve and it is creating a shortage of consultants due to changes in compensation. In the end, it is a matter of weighing the costs and the benefits and accepting that there is still work to be done. (more…)

You probably don’t need anything else to be thankful for, but just in case what you have been so patiently for is finally here – the last two video installments of our “Health Reform After the 2010 Election: Assessing the Viability of Health Insurance in the Aftermath of the Mid-Term Elections” event. That’s right… as a special holiday treat, we have not one but TWO segments for you today – chock full of information and analysis about what the midterm elections could mean for health care reform and, more importantly, how these changes could affect YOUR life, YOUR insurance and YOUR health care.

So grab some popcorn (or one more little slice of pumpkin pie), cuddle up by the fire with your laptop and click away at the links below!

In the States: The Future of Health Insurance

In the Trenches: Who Will Buy What From Whom

For those of you who missed our previous post about our Health Reform After the 2010 Election event, you can read it and watch the first video segment here.

Happy Thanksgiving from all of us Disruptive Women!

By Stephanie Cohen.

This month’s health insurance issue: Linda is having surgery in the morning, but at 4 p.m. the afternoon before, she gets a call from her HMO requiring her to post a $400 advance deposit — or the surgery is off. What should she do?

The situation: Our client Linda was scheduled to have surgery using a surgical group that had negotiated fees with her HMO carrier. Besides being told to post $400 in advance, she was told she needed to sign a form stating she would pay whatever fees the carrier would not pay to the doctor.

This came despite the fact that the surgeon was in her HMO network and Linda had gotten the proper referral and authorization from the carrier. In fact, her policy dictates that when a provider has signed a contract with an insurance carrier, the patient is held harmless from all fees associated and cannot be asked for additional payments other than applicable copays, deductibles, and coinsurance. In this case, the policy had a $20 doctor copayment and 100% coverage, with no hospital copayment.

Linda called us in a panic, and we immediately phoned our contact at her HMO. Due to the late hour, our contact couldn’t do anything until the following morning, when she would have a representative from provider relations step in. And after a long discussion with the insurance company, Linda did not have to post the deposit and did have a successful surgery.

The solution: Don’t assume anything before having surgery. Get on the phone and make sure you are covered.

1. Contact the insurance provider and verify all benefits. Always get the name of the representative you talk to, as well as the department name and number. Try to speak with a supervisor. Also, note the date and time you had the discussion, since all calls are recorded and can be pulled to make sure accurate information was given.

2. Get all pre-authorization agreements in writing. Typically, the doctor’s office will call, but you should insist on getting it in writing, too, so you can be sure everyone involved in the surgery — the surgical center, hospital, anesthesiologist, doctors, etc. — is covered by your health insurance plan.

3. Understand your policy and be clear about the items that you may be required to pay for. Many hospitals, surgical centers, radiological providers, and labs will send you a bill in addition to submitting it to the insurance company. Remember:: Never pay a bill unless the insurance company has received it first and re-priced it (including applicable discounts) and until you have received evidence of benefits that match the bill.

The painful truth: Unfortunately, the system is broken. Insurance carriers, doctors, and patients will continue to eek out whatever they can from the health-care and insurance system until new policies are in place that make it clear exactly what the contract is that they are entering into. If anything is unclear in your agreement, a new one needs to be worked out that will include cost, payment, and what insurance covers.

If we were the Health Insurance Ambassadors: We would require that all doctors notify the patient about the exact cost of the surgery before the procedure. The patient would then have a full understanding of the costs associated with the surgery and the doctor would receive the appropriate payment.

In defense of doctors, we would also change how they take payments. Doctors do not ask for money upfront. They provide a service and hope that they will receive payment afterward. Perhaps they should swipe a credit card before the procedure or at the time of an office visit.

Originally posted on http://www.beinkandescent.com/articles/251/scott-golden-and-stephanie-cohen.

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.

(more…)

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

(more…)

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.