Australians already know that health coverage can provide security for individuals and families when a medical need arises. Many, however, do not know how to find the best value when comparing health insurance policies.
Below are 10 tips everyone should read before shopping for private health coverage.
1. Choose coverage that concentrates on your specific health needs, or potential health needs.
The first thing you should do before comparing your health plan options is determine which policy features best fit your needs. A 30-year-old accountant, for instance, is going to need very different coverage than a 55year-old pro golfer, or a 75-year-old retired veterinarian. By understanding the health needs that most often correspond to people in your age and activity level group – your life stage – you can save money by purchasing only the coverage you need and avoid unnecessary services that aren’t relevant. For instance, a young family with two small children isn’t going to need coverage for joint replacement or cataract surgery. A 60-year-old school teacher isn’t going to need pregnancy and birth control-related services.
Whether it’s high level comprehensive care you’re after, or the least expensive option to exempt you from the Medical Levy Surcharge while providing basic care coverage, always make sure you’re comparing health insurance policies with only those services that make sense for you and your family.
2. Consider options such as Excess or Co-payment to reduce your premium costs.
When you agree to pay for a specified out-of-pocket amount in the event you are hospitalized, you sign an Excess or Co-payment option that will reduce your health insurance premium.
If you choose the Excess option, you agree to pay a predetermined, specific amount when you go to hospital, no matter how long your stay lasts. With a Co-payment option, you agree to pay a daily sum up to a pre-agreed amount. For example, if Joanne has an Excess of $250 on her medical coverage policy and is admitted to hospital, regardless of how long her stay turns out to be, she will pay $250 of the final bill. If Andrew has signed a $75×4 Co-payment with his provider, he will pay $75 per day for just the first the first four days of his hospitalization.
For younger individuals who are healthy and fit with no reason to expect to land in hospital any time soon, either of these options are great ways to reduce the monthly cost of your medical insurance premiums.
Keep in mind that different private insurers have their own rules when it comes to Excess and Co-payments, including how many payments you will need to make annually on either option. It is important to read the policy thoroughly and ask questions in advance in order to have a clear understanding of what you are paying for, and what you can expect coverage-wise in the event that you are hospitalized. Also, make sure you choose an Excess option greater than $500 if you’re purchasing an individual policy, or $1,000 for family coverage, in order to be exempted from the Medicare Levy Surcharge.
3. Pay your health insurance premium in advance before the cost increases.
Each year insurance providers increase their premiums by approximately five percent sometime around the first of April, a practice approved by the Minister of Health. By instituting these annual increases, your health insurance provider retains the ability to fulfill their obligations to policyholders despite increasing medical costs.
Most private medical policy providers allow policy holders to pay for one year’s premium in advance, which locks them into the previous year’s rate for an additional 12 months – a great way to save money. In order to take advantage of the savings offered, most insurers require payment in full be made within the first quarter of the year, between January and March.
4. Lock in to low cost health insurance at an early age.
The most obvious advantage any Australian can take when it comes to saving money on your insurance premiums is to buy in early to the least expensive rate available. And by early, we mean before age 31. Everyone who is eligible for Medicare will receive at least a 30 percent rebate from the government on the price of their health care premium, no matter what age you are. However, by purchasing hospital coverage before the July first following your 31st birthday, you can be ensured the lowest premium rate available.
After age 31, your health insurance rate is subjected to a two percent penalty rate increase for every year after age 30 that you did not have health insurance. Therefore, if you wait to purchase private health coverage until you’re age 35, you will pay 10 percent more annually than you would have if you had purchased it at age 30.
There are exemptions for some people who were overseas when they turned 30, or for new immigrants, and certain others under special exception status. However, if you purchased private insurance after age 30 and are paying an age loading penalty on your health coverage, you will be relieved of the excess penalty after 10 years of continual coverage.
The earlier in life that you lock in to a private health plan, the more money you will save both immediately and over your lifetime.
5. Choose a health care provider who already works with your health fund.
Determine which hospital you prefer if and when the need for treatment does arise, and seek out those health insurance providers that have an agreement with your hospital of choice before making a decision on your health insurance purchase.
It’s a good idea to also find out if your insurer has a list of “preferred providers,” which would include those physicians and practitioners who also have made arrangements with the health funds regarding their charges for services. Request this information from every provider when comparing health insurance policies. This way you can be sure you’ll receive the full gamut of benefits available at the lowest possible cost. These preferred providers often have “no gap” cover – special rates that reduce or eliminate out-of-pocket expenses to policyholders.
6. Double check your health insurance policy before you schedule any treatment or procedures to make sure you have coverage.
Any time you are headed to a private hospital for treatment, first check to see if the hospital and your health insurance provider have an agreement to be absolutely sure you have adequate coverage. At the same time, check with your insurance provider, physician and the hospital to see if there is a Gap between their fees and the government’s Medicare Benefits. This is extremely important because if your physician charges more than Medicare covers and you do not have a “no Gap” plan set up, you could find yourself responsible for a considerable bill. Simply contact your doctor and your insurance company to double check on these items, and avoid being saddled with an out-of-pocket expense your weren’t expecting.
7. File your expense claims promptly.
When you have a health insurance membership card, you can file a claim against your benefits at the time of treatment with no additional paperwork or filing to worry about, at least in most cases. Sometimes, you may still need to file a claim with your insurance provider. When that happens, make sure to file your claim promptly. The typical cut off for insurers to pay health care claims is two years. You can file your health insurance claim directly with your provider or at your area Medicare office, which has a reciprocal agreement in place with most insurance providers.
8. Whenever you travel overseas, suspend your health coverage.
Anytime you travel overseas for more than a few weeks but less than 24 months, certain medical insurance providers allow policyholders to suspend their memberships for the time they’re out of the country, freeing the policyholders from paying premiums during that time period. While your insurance policy is suspended, your Lifetime Health Cover status remains intact, so you do not have to worry about age loading added when you return home. Contact your health insurance provider to make sure of their policy and rules regarding waiting periods and re-activation.
Remember too that Australia has reciprocal arrangements in certain countries, including New Zealand, Finland, Ireland, Italy, Malta, the Netherlands, Sweden and the U.K. For more information, visit http://www.smartraveller.gov.au.
9. Review your policy benefits annually.
Lifestyles change, individuals get married, have children, age – children grow up and move out on their own, couples separate. A lot can happen in the span of 12 months, which is why the Private Health Insurance Ombudsman recommends that everyone review their policy benefits once every year to make sure your coverage still fits your needs.
Regardless of your life changes, your Lifetime Health Cover status remains protected, and waiting periods for benefits that equal your current coverage are waived in compliance with the Private Health Insurance Act of 2007. This means you will be able to file claims related to features you had before you made any changes without interruption in benefits.
10. Compare policies to get the best price and the coverage you need.
To make sure that you are getting the best possible price on your health insurance premium, you must compare policies from different insurers, Make sure you are comparing policies that reflect the treatment plan and coverage you need, without filler services that you won’t need. The more you know about private health coverage and government sponsored Medicare, the more likely you will find the best value for your money when it comes time to purchasing or renewing your health coverage.
Author Liz Ernst writes on health insurance matters in Australia and the U.S.
Private health insurance is a cost Australians should at least consider factoring into their budget. Different funds have products that better suit different groups of people. Visit the Your Health Insurance website (http://www.yourhealthinsurance.com.au) to compare pricing and policies, and learn more about buying health insurance in Australia.
It really does pay to shop for health insurance.
With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.
Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.
Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.
THE PROBLEM OF COST
No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.
Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.
WHY HAS HEALTH CARE BECOME SO COSTLY?
This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).
Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.
Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).
Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.
Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.
Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.
In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:
1. Technological innovation.
2. Overutilization of health care resources by both patients and health care providers themselves.
Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.
Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.
Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.
A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:
1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.
2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.
3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.
4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).
5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.
Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).
How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.
In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.
But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—
WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?
According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.
This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?
People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).
So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.
But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.
Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).
THE PROBLEM OF ACCESS
A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.
GUIDELINES FOR SOLUTIONS
As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.
Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:
1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.
2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.
3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.
4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:
* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).
* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).
* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.
Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.
Article Source: http://EzineArticles.com/2772660
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While sitting back in her blue jeans and wearing a heavy workout sweater at the Legacy Emanuel Hospital’s Emergency room, Angela Jones has her feet prompted up and crossed atop of a small table. When asked about health care issues and how they affect her, Angela explains that there is a portion of people who suffer from not having health care insurance. She makes it clear that some of those who suffer most are young people. Jones, who is a college student, declared her passion for the young because it falls under her own age group.
Says Jones, “The Oregon Health Plan should be open to more people who are under 21 years old. Private insurance shouldn’t be so expensive for young people.”
According to national surveys, the primary reason people are uninsured is the high cost of health insurance coverage. Notwithstanding, nearly one-quarter (23 percent) of the uninsured reported changing their way of life significantly in order to pay medical bills. Economists have discovered that increasing health care costs correlate to drops in health insurance coverage.
Jones believes that some of the greatest challenges that people face across this nation is obtaining affordable health care. “I would open an Oregon Health Plan to a variety of people who don’t have insurance. It is hard to get health insurance.”
Terri Heer, a registered nurse at a local hospital, claims that in order to improve America’s health care system a key ingredient is to “make sure that everyone (has) access.”
This would include cutting out on expenses that are not palpable to so called “health care needs”. Heer says, “First, we spend a lot of money servicing people for illnesses that can be prevented. Some of the money spent can go to other things.”
Over the long haul, should the nations health care system undergo significant changes, the typical patient may not necessarily see the improvements firsthand. “I would love to say there will be a lot of changes. I am not a pessimist, but I don’t think there will be any change,” says Heer. Heer does allude to the fact that if more money were spent for people in the health care arena, she says that there is a possibility that the necessary changes would be more evident.
Whether health care is affordable or not is an issue that affects everyone. According to a recent study last year, health care spending in the United States reached $2.3 trillion, and is projected to reach $3 trillion by 2011. By 2016, it is projected to reach $4.2 trillion. Although it is estimated that nearly 47 million Americans are uninsured, the U.S. spends more on health care than any other nation.
The rising tide of health care stems from several factors that has an affect on us all. First, there is an intensity of services in the U.S. health care system that has undergone a dramatic change when you consider that people are living longer coupled with greater chronic illnesses.
Secondly, prescription drugs and technology have gone through significant changes. The fact that major drugs and technological advancement has been a contributing factor for the increase in health care spending. Some analysts suggest that the improvement of state-of-art technologies and drugs increase health care spending. This increase not only attributes to the high-tech inventions, but also because consumer demand for these products has gone through the roof, so to speak.
Thirdly, there is an aging of the population. Since the baby boomers have reached their middle years, there is a tremendous need to take care of them. This trend will continue as baby boomers will qualify for more Medicare in 2011.
Lastly, there is the factor of administrative costs. Some would argue that the private sector plays a critical role in the rise of health care costs and the economic increase they produce in overhead costs. At the same time, 7 percent of health care expenses are a result of administrative costs. This would include aspects of billing and marketing.
Terra Lincoln is a woman who was found waiting in the Emergency room at the Providence Portland Medical Center. When asked about the rising costs of health care, she said, “If you don’t have medical coverage, it’ll cost you too much money. If I leave the hospital right now and I need to buy two (types) of medicines, I couldn’t afford it.” Lincoln says that she is a member of the OHP, but she believes that there are still issues that need to be addressed.
Terra recognizes that to reduce medical costs, she would have to start by getting regular checkups. “Sometimes people of color wait till they’re in pain before they get a checkup,” she said.
A national survey shows that the primary reason why people cannot afford health care is because of soaring costs of health care coverage. In a recent Wall-Street Journal-NBC survey it is reported that 50% of the American public claims that their highest and most significant economic concern is health care. Consequently, the rising cost of health care is the number one concern for Democratic voters.
Regarding the rising tide of health care, Kristin Venderbush, a native Wisconsin, and another patient in emergency at Providence says, “I worry a lot about what happens to the working poor. They don’t have OHP. If you can’t advocate for yourself, you will not get the health care you need…on every level.”
Harvard University researchers conducted a recent study that discovered that the out-of-pocket medical debt for an average consumer who filed bankruptcy was $12,000. This study noted that 68 percent of those who had filed for bankruptcy carried health insurance. Apparently, these bankruptcy’s were results from medical expenses. It was also noted in this study that every 30 seconds someone files for bankruptcy after they have had some type of serious health problem.
In spite of all the social and economic bureaucracy in the health care arena, some changes were made in Washington on January 28, 2008. In his State of the Union address, President Bush made inquired Congress to eliminate the unfair bias of the tax code against people who do not get their health care from their employer. Millions would then have more options that were not previously available and health care would be more accessible for people who could not afford it.
Consequently, the President believes that the Federal government can make health care more affordable and available for those who need it most. Some sources suggest that the President not only wants health care to be available for people, but also for patients and their private physicians so that they will be free to make choices as well. One of the main purposes for the health care agenda is to insure that consumers will not only have the freedom to make choices, but to also enable those to make decisions that will best meet their health care needs.
Kerry Weems, Acting Administrator of the Centers for Medicare and Medicaid Services, oversees the State Children’s Health Insurance Program, also known as SCHIP. This is a critical program because it pays for the health care of more than six and a half million children who come from homes that cannot afford adequate health insurance. These homes exceed the pay scale for Medicaid programs, therefore are not able to participate.
During SCHIP’s ten year span, states have used the program to assist families with low-income and uninsured children for their sense of well-being in the health care arena. The Bush Administration believes that states should do more of an effort to provide for the neediest children and enable them to get insurance immediately. The SCHIP was originally intended to cover children who had family incomes ranging from $20,650. This amount would typically include a family of four. According to sources, all states throughout the U.S. have SCHIP programs in place and just over six million children are served.
Children and Health Care
What is driving health care costs?
The fact that the U.S. faces ever increasing health care woes, has left many to believe that the country’s current crisis is on a lock-step path toward insolvability.
Employer-based retirement health care insurance benefits continue to decline, according to recent industry reports.
Many retirees have been able to rely on private or state employer-based retirement health benefits for supplemental health care coverage while on Medicare in the past, but this is becoming less common.
Employer-based health-related benefits can provide important coverage for the gaps that exist in Medicare programs. Additional coverage benefits can alleviate the cost-sharing requirements and deductibles associated with Medicare. Caps on the amount that can be spent out-of-pocket, often associated with supplemental coverage, are also often helpful for retirees.
Overall, supplemental retiree health and medical benefits sponsored by a private or municipal employer have helped many retirees cope with high medical costs often incurred in retirement.
The Kaiser Family Foundation recently reported, however, that the number of large private employers-considered employers with 200 or more employees-offering retiree healthcare benefits has dropped from 66 percent in 1988 to 23 percent in 2015.
Companies that do continue to offer retiree health benefits have been making changes aimed at reducing the cost of benefits, including:
Instituting caps on the amount of the provider’s financial liability
Shifting from defined benefit to defined contribution plans
Offering retiree health care benefits through Medicare Advantage plan contracts
Creating benefit programs through private health insurance exchanges
State employers have also not been immune to the trend, but the type and level of coverage being offered by most states is significantly different than retirement health care coverage being offered by large companies.
Unlike many private employers, state governments continue to offer some level of retiree health care benefits to help attract and retain talented workers, according to a report titled “State Retiree Health Plan Spending,” published by The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation in May, 2016.
With the exception of Idaho, all states currently offer newly-hired state employees some level of retirement health care benefits as part of their benefits package, according to the report. Of the states offering retiree medical benefits, 38 have made the commitment to contribute to health care premiums for the coverage being offered. State employers are, however, also making changes to the retirement health care insurance benefits they provide to state workers.
Significant among these changes for the states is at least one driving force-the Governmental Accounting Standards Board (GASB) now requires states to report liabilities for retirement benefits other than pensions in their financial statements. The changes were required from all states by the end of 2008. As a result, the increased financial transparency forced states to review the cost of their other post-employment benefits (OPEB) and address how they plan to pay for them.
Because retirement health care benefits account for the majority of the states’ OPEB obligations, many states have made policy changes to address the upcoming obligations. Factors such as date of hire, date of retirement or vesting eligibility, including minimum age and minimum service year requirements, are now being used by states to vary or limit retirement health care benefits.
Overall, from 2010 to 2013, the states saw their OPEB liabilities decrease by 10 percent from $627 billion after inflation adjustments. While this may sound contradictory, the declines are attributed to a slowdown in the growth of health care costs coupled with benefit modifications aimed at cost reductions.
To look at one state as an example, California’s recent budget revealed that health care benefits for retirees are costing the state more than $2 billion a year for an 80 percent increase over the prior 10 years. Although the situation recently changed, California was previously one of 18 states that had nothing set aside to cover its future retiree health care benefit costs of $80.3 billion.
It should be noted that retiree health care plans are typically funded by plan sponsors on a “pay as you go” basis, meaning that monies to pay current and future health care obligations are taken from current assets and not set aside in advance. This differs significantly from pension plans governed by ERISA, which are subject to funding guidelines.
In response to California’s unfunded OPEB liability, employees and the state are now paying into a fund for future retiree health care benefit costs. The state is also matching $88 million in employee contributions and paying an additional $240 million to prefund future retirement health care benefit costs. The changes are impacting retirees as well as state and private employers.
Overall, employer-based retirement health care benefits, once important for supplementing Medicare for retired seniors, continue to decline.
The Potential Impact of Eroding Employer-Based Health Care Retirement Benefits
Many baby boomers who are currently covered by retiree medical plans and plan to rely on future employer-paid medical benefits, are likely to be disappointed to learn that these benefit plans can be changed or terminated. ERISA-governed benefit plans typically contain a “reservation of rights” provision allowing the plan sponsor to change or terminate all or parts of the plan. Many private and state employers are reducing or terminating retiree health benefits due to the increasing cost of insurance premiums, rising health care costs, and increases in longevity.
Since the early 1990s there have been many cases where unexpected changes to post-employment pension and medical benefits have resulted in lawsuits. Typically, the key issue is the reservation of rights language and/or collective bargaining agreement language for employees who were covered by a union contract which referenced retiree medical benefits.
Beneficiaries who have questions about their retiree medical benefits should speak with their plan sponsor to learn about the specific benefits available to them and have a contingency plan for bridging their medical coverage to Medicare, if they are considering early retirement or want to better understand future benefits.
Mark Johnson, Ph.D., J.D., is a highly experienced ERISA expert. As a former ERISA Plan Managing Director and plan fiduciary for a Fortune 500 company, Dr. Johnson has practical knowledge of plan documents as well as an in-depth understanding of ERISA obligations. He works as an expert consultant and witness on 401(k), ESOP and pension fiduciary liability; retiree medical benefit coverage; third party administrator disputes; individual benefit claims; pension benefits in bankruptcy; long term disability benefits; and cash conversion balances. He can be reached at 817-909-0778 or via http://www.erisa-benefits.com.
Unless you routinely go for a mani-pedi, odds are high that you don’t give careful consideration to your nails regularly. Notwithstanding, the path in which they look and feel really says a considerable measure in regards to your wellbeing, and there are sure things that you unquestionably shouldn’t disregard. On the off chance that you have liver, thyroid, heart or lung issues, for instance, you will see the primary indications of this by breaking down your fingernails. This is what to pay special mind to.
Ridges or ripples don’t necessarily mean that something is seriously wrong with you; however, they can be a sign that you have a common skin disease known as psoriasis, or that you are at risk of developing inflammatory arthritis in the near future.
Many people will argue that white marks indicate a calcium deficiency. This, however, isn’t always the case. In reality, the white marks are more likely to form if you have knocked your nail(s) on a hard surface. With this in mind, persistent white marks that cover large portions of the nails could indeed also suggest calcium, protein (anaemia) or zinc deficiency. If in doubt, it is best to visit your doctor for some blood tests.
Nail-polish can often result in a yellow tinge on the tips of the nail, especially after removing darker colours. However, if you are not someone who uses nail-polish regularly, this yellowing could be a sign of a nasty fungal infection, and if left untreated, could cause the thickening and crumbling of the fingernails over time, resulting in nail loss.
If your nails seem to curve over the finger and all around, resulting in a club-like appearance, it is usually an indication of low oxygen levels in the blood. This could be a sign of impending heart and / lung or problems, as well as IBS.
Separation from the Nailbed
This unpleasant, and often painful, condition is known as onycholysis and can be brought about after an injury. However, it can also occur as an allergic reaction to a product or as a result of thyroid problems.
While there might be nothing wrong with your health, if however you do notice that your fingernails are less than perfect, it pays to be prepared. Be sure to invest in a reliable health scheme that provides you with the cover that you need should you ever find yourself in poor health. And remember – pay attention to any changes in and on your body, especially regarding your nails. It could lead to the early detection of a more serious problem and thus ensure that it is easy to treat.