Category: Health Care

by Dave Mindeman

Republicans are ramping up their opposition to Democratic Health Care proposals. And once again, it is, or will be, the government's fault that health care is out of control. The single payer bogeyman is a great target. You can always get a good scare campaign going about something you never give a chance to work.

But the GOP messages often conflict.

John Kline offers this quote:

"If Democrats are serious about including a so-called government-run 'option' in their plan ? and if a government-run 'option' is designed to crowd out the private sector ? then the reality is that we are only a few steps away from a single payer system."

Kline says that a government option "could drive private insurers out of business". Now, if the government option is going to drive insurers out of business, don't we have to assume that it is a better and more cost effective plan? That is the rule of the market place is it not?

Yet, here in Minnesota the local GOP talking points are latching onto the "mandate problem". Conservative blogger Gary Gross, at Let Freedom Ring, had the opportunity to ask some questions of Rep. Paul Ryan....the lead guy on the US House version of their health care "alternative".

The Minnesota mandates came up:

Q: Here in Minnesota, there are 65 separate mandates on health insurers, all of which drive up the cost of a health insurance premium. With Ted Kennedy & Co. writing health care ?reform?, isn?t it likely that their legislation will contain lots of expensive mandates? Wouldn?t that necessarily drive up health care costs?

A: Yes. That is one of the major problems with a public plan. Insurance shouldn?t be one-size-fits-all. The public plans being proposed by Ted Kennedy and others will likely mandate a lot of coverage that not everyone needs, making it more expensive for everyone. We?ve seen this problem at a state level where a state mandates coverage for something like hair regrowth formula ? that only a small percentage of the population even wants access to ? but ultimately, those mandates drive up the cost of insurance for everyone, even those who don?t use much coverage at all. The Patients? Choice Act addresses this problem by allowing insurance plans that sell health insurance through state exchanges to be exempt from these mandates. These plans only need to meet the minimum benefit standard prescribed by the Federal Employee Health Benefits Plan. People need to be able to purchase health insurance that isn?t heavily loaded with mandates.

Which increased my curiousity. What is involved with those 65 mandates? Although I am still tracking some of them down, I did find a partial list at the Kaiser Family Foundation site regarding State Health Facts.

I am assuming the definition of mandates is that the state requires insurance companies to cover specific procedures that they would otherwise have an option to NOT cover.

The Kaiser list of mandates in Minnesota include:

Cancer Screening for Women--breast cancer
--cervical cancer
--ovarian cancer

Reconstructive Surgury after a Mastectomy

Direct Access to OB/GYN's (I assume that means without a necessary referral procedure)

Cover treatment for eating disorders.

Mandated coverage for maternity care (Yes, believe it or not Minnesota had to require insurers to cover that)

As you can see, a lot of these mandates refer to coverage specific to women. Did private insurers discriminate against women's health? Oh, yes. And they still do in many areas.

So, there you are. Single payer is dangerous because it is too "competitive" for the private insurers. While at the same time it costs too much because it mandates coverages.

I guess we need to stay with the current system. You know, the system that depends on private insurers with 30 and 40% administrative costs and which only cover things that won't cost them too much money....especially if they can get rid of those pesky mandates outlined above.

You know, that system.

P.S. -- I am sure you will be relieved to know that Minnesota does not mandate "hair regrowth formulas"....whew!

Category: Health Care

by Dave Mindeman

President Obama has a health care initiative in mind. It is not the kind of proposal I would prefer, but some kind of action needs to be taken.

Most of the early information deals with how it will be paid for , as well as other parts of an enormous budget....and we are talking about massive funding.

This budget and health care initiative uses the tax money that will come from the expiration of the Bush tax cuts enacted during his first term. Now before you get misled by conservative rhetoric, the tax rate will be changing from its current 35% on income over $200,000 to the 39.6% that was the rate during the Clinton administration.

In addition, deductions on mortgage interest and charitable giving will be allowed at a reduced rate of 28% rather than the current 35%. The deduction change could be very controversial -- charitable recipients will be objecting.

Another source of funding will come from the long awaited carbon emissions cap and trade:

The plan also contains a contentious proposal to raise hundreds of billions of dollars by auctioning off permits to exceed carbon emissions caps Obama wants to impose on users of fossil fuels to address global warming.

How that is handled will define climate change policy over the next decade. The details on that program will get enormous Congressional scrutiny and will probably emerge as a very different program than the initial administration proposal.

Getting back to Health Care....the administration is looking at large cuts in Medicare. That is going to produce a lobbyist war among the stakeholders in the Medicare program...the doctors, the drug companies..the insurance companies. There will also be a premium bump on Medicare recipients who are wealthier.

I still firmly believe that a simple, single payer plan based on the Medicare formula can introduce enough cost savings to the program to greatly reduce the amount of additional revenue necessary. It is obvious that Obama is not going to even consider that route...and that is too bad.

However, any plan that can expand the number of insured Americans is moving in the right direction. You just would think that universal coverage and cost efficiency would be goals you would seek in tandem..... and the truth is, they could.

I hope the President succeeds in his plans.... but I think we will be revisiting the cost issue again. But hopefully when we do, the dynamics of universal coverage will be in place.

Category: Health Care

by Dave Mindeman

The terminology and references to the health care debate always gets lost in assumptions and inaccurate comparisons. As we sink deeper into an economic nightmare, health care should come to the forefront -- because fixing it can speed up our economic recovery.

My perspective comes from two things: I am a pharmacist and see health care issues up close....and my wife has a chronic illness that requires constant insurance involvement. Secondly, I have come to believe strongly in the single payer solution. And as I discuss some of these things, you will see why.

Right now, I want to discuss the daily grind that providers deal with regarding insurance issues. Most of my references are going to involve PBM's (Pharmacy Benefit Managers) -- Doctors and hospitals have more issues but have to deal with PBM's as well.

Several years ago, PBM carriers were touted as an answer to skyrocketing health care costs. They would reduce costs by making claims and benefits more efficient. And at first, they did slow some of the escalating costs. Briefly. But they very quickly reversed that trend as profit motives required more squeezing of providers and patients.

Here are a few of the ways PBM's have complicated health care:

DUR (Drug Utilization Reviews) -- In theory, this should have added to health care quality. What it is supposed to do is examine a drug claim and compare it to recent claims for the same patient to look for drug incompatibilities, overuse, and dosage problems. Pharmacies have their own internal checks but with patients filling prescriptions at multiple locations, it can be hard to keep track of a patient's history. But, although well intended, DUR has ended up adding to costs.

Here is an example: A woman brought me a prescription for a rather high dose of Warfarin -- a blood thinner. The dose was higher than recommended on a normal basis, but this patient had a special situation and the doctor insisted that the dose was correct. The insurance carrier blocked me from filling the presciption citing a DUR violation. After calling the insurance company, they told me the remedy would be a prior authorization application (you will be hearing a lot about prior authorization). In order to obtain an override in this manner, the Doctor (not the pharmacy which had already done the calls and verification) would have to submit a PA request. So, the doctor calls the insurance company and files a form -- a review board decides whether the reason is sufficient and if they agree, they authorize the claim. Notice that the review board...not the doctor... has the final say. One more thing, this woman had obtained a prior authorization for this dosage in 2008; however, her place of employment had changed the plan with this carrier (same insurance company, just a different plan) which invalidated the previous prior authorization and required everyone to go through the whole process again.

Efficient?

Refill Too Soon -- Again, for well intentioned reasons, this method of denying a claim is meant to evaluate whether or not a patient is overusing a medication. Unfortunately, most insurance carriers don't seem to understand that patients do go on vacation, or sometimes lose bottles, drop pills down the sink by mistake, or have changes in dosage by the doctor. So, the pharmacy has to call the insurance company and obtain an override. The request is usually granted -- but the hoops must be jumped through so that the carrier can document such events. Some carriers will "allow" only two such events within a year -- if a third time is required, the patient either pays cash or goes without. In addition, everytime this call is made requires long phone waits on hold with the carrier. Time wasted -- administrative costs added.

Non-Formulary Drug -- Here is another example of care being controlled by the insurance. Doctors often prescribe a specific drug for a course of treatment, but the insurance company has decided that a "less expensive" therapeutic equilavent is the preferred drug. Preferred drugs are put on a "formulary" list. The non-preferred drugs may still be allowed but have to go through a prior authorization process. The Doctor has to provide a reason for using that particular brand. Often, the only reason the insurance carrier prefers one drug over another is that the preferred has a generic alternative which will greatly reduce the cost to the insurance company. One extreme example of this is that I had a patient that needed to use the brand name Zocor for cholesterol. The insurance required that the generic be used, however, this patient had a reaction to the tablet color dyes of any the generics we could get. After several weeks of haggling, the insurance carrier allowed the brand product but reduced the pharmacy reimbursement to the point that we lost money every time this person had the Zocor filled.

These are just some examples of how insurance carriers control health care in America. Doctors, Dentists, and Hospitals have other stories to tell I am sure.

I'll be going over additional problems with the so-called "competitive health care model" in future posts..... as well as why single payer can improve the situation immensely.

Health care is being held hostage by a system that has too many complications and rules. If we are to compete in a global market, one area that we are losing badly in, is health care.

Maybe we can overcome our economic issues -- but without fixing health care, we will only get dragged down again.