Tuesday, September 30, 2014

Fwd: qotd: Auto-renewal of health plans is a problem we don’t need

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From: Don McCanne <don@mccanne.org>
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Subject: qotd: Auto-renewal of health plans is a problem we don't need
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The New York Times
September 29, 2014
Auto-Renewing Your Health Plan May Be Bad for You, and for Competition
By Austin Frakt

Overwhelmed with increasing choice in the new exchanges, returning
consumers may not relish the idea of selecting a new plan. A feature
built into the exchanges practically invites them not to do so:
auto-renewal. Consumers insured by an exchange plan this year who do not
actively choose a new one for next year will be automatically
re-enrolled in their current plan or automatically enrolled in a similar
one if their plan is discontinued. This auto-renewal is meant to help
increase and maintain the size of the insured population and to promote
continuous coverage. But if people rely on auto-renewal without
evaluating all available options, some may end up in plans that aren't
ideal for them.

Next year, the premiums of the currently cheapest silver-rated plans are
going up by an average of 8.4 percent. Because of that, many of those
plans will no longer be the cheapest. The customers who switch to the
silver plans that are the cheapest in 2015 will see their premiums rise
by only 1 percent on average.

Auto-renewal also offers insurers a way to retain customers without
vigorously competing for them, counting on the fact that some consumers
will stick with their plans even when, rationally, they should not.

Here, basic economic theory is in conflict with the finding from
behavioral economics that when choices become too numerous and complex,
consumers resort to heuristics (or shortcuts), leading to suboptimal
decisions. For instance, when we can't fully evaluate all options, we
tend to default to familiar brands. And, because it takes time and
effort to re-evaluate options, we tend to stick with our initial choice
of brand when making a new purchase.

If we want more competition, we need to induce fewer people to default
to auto-renewal.

Auto-renewal exists for a reason, but if consumers rely on it too much,
the results will include higher premiums and greater market power for
insurers.


NYT Comments:

Don McCanne
San Juan Capistrano

Under a well designed single payer national health program there would
be no need to choose networks since the entire health care delivery
system is covered, and there would be no need to shop deductibles since
they would be eliminated.

The problem of auto-renewal would disappear since enrollment would be
for life.

http://www.nytimes.com/2014/09/30/upshot/auto-renewing-your-health-plan-may-be-bad-for-you-and-for-competition.html

Monday, September 29, 2014

Fwd: qotd: When your emergency physician is out of your network

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The New York Times
September 28, 2014
Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not
By Elisabeth Rosenthal

Patients have no choice about which physician they see when they go to
an emergency room, even if they have the presence of mind to visit a
hospital that is in their insurance network. In the piles of forms that
patients sign in those chaotic first moments is often an acknowledgment
that they understand some providers may be out of network.

But even the most basic visits with emergency room physicians and other
doctors called in to consult are increasingly leaving patients with
hefty bills: More and more, doctors who work in emergency rooms are
private contractors who are out of network or do not accept any
insurance plans.

When legislators in Texas demanded some data from insurers last year,
they learned that up to half of the hospitals that participated with
UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas's three
biggest insurers — had no in-network emergency room doctors.
Out-of-network payments to emergency room physicians accounted for 40 to
70 percent of the money spent on emergency care at in-network hospitals,
researchers with the Center for Public Policy Priorities in Austin found.

"It's very common and there's little consumers can do to prevent it and
protect themselves — it's a roll of the dice," said Stacey Pogue, a
senior policy analyst with the nonpartisan center and an author of the
study.

When emergency medicine emerged as a specialty in the 1980s, almost all
E.R. doctors were hospital employees who typically did not bill
separately for their services. Today, 65 percent of hospitals contract
out that function. And some emergency medicine staffing groups — many
serve a large number of hospitals, either nationally or locally — opt
out of all insurance plans.

Regulations created by the Affordable Care Act specify that insurers
must use the best-paying among three methods for reimbursing
out-of-network physicians dispensing emergency care: pay the Medicare
rate; pay the median in-network amount for the service; or apply the
usual formula they use to determine out-of-network reimbursement, which
often depends on "usual and customary rates" in the area.

But in most states, doctors can then bill patients for the difference
between their charge and what the insurer paid.

http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html

Center for Public Policy Priorities study of out-of-network emergency
room doctors:
http://forabettertexas.org/images/HC_2014_09_PP_BalanceBilling.pdf

KFF on state balance billing restrictions:
http://kff.org/private-insurance/state-indicator/state-restriction-against-providers-balance-billing-managed-care-enrollees/

****


Comment by Don McCanne

A consequence of allowing health insurers to contract selectively with
health care professionals (physicians) and institutions (hospitals) is
that patients not only are financially penalized should they elect to
obtain their care outside of the contracted networks, they may
unavoidably face such penalties when they have sought care only within
networks.

One of the more egregious examples is when they obtain emergency
services at a contracted emergency room only to find out after the fact
that the physicians staffing the emergency room are not in the network.
The patient then is billed not only for deductibles and copayments
applied to allowed charges, but also for the balance of the charges in
excess of the allowed charges - a process known as balance billing.

"The Affordable Care Act provides some protections for enrollees in need
of emergency services, but does not prohibit balance billing by
out-of-network providers" (KFF). For further information on state
restrictions on balance billing, use the KFF link above.

When something is not right, as it clearly isn't here, it is important
to define the problem before crafting a solution. State regulators and
legislators are defining this as a problem of balance billing "abuse"
and are looking at mechanisms to prohibit balance billing. But is that
really the problem?

Insurers, with the complicity of state and federal legislators, have
established limited networks of providers to leverage more favorable
payment rates for health care services. But these rates neglect the
health care delivery system outside of the networks. Now states are
considering making out-of-network physicians comply with contracts to
which they never agreed. That is as unreasonable as making insurers pay
out-of-network fees in full simply because the insurers did not have a
contract with the physicians. Do you have a contract or not? You can't
have it both ways.

The problem here needs to be redefined. Balance billing is not the
primary defect. It is the nature of our complex, dysfunctional financing
infrastructure that leads to a multitude of perverse consequences such
as balance billing - an infrastructure that was perpetuated and expanded
by the Affordable Care Act. We need to rebuild the infrastructure. We
need a single payer national health program. Balance billing would not
exist under such a system.

Friday, September 26, 2014

Fwd: qotd: Community health centers stuck with unpaid bills for insured patients

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From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
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Subject: qotd: Community health centers stuck with unpaid bills for
insured patients
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Kaiser Health News
Daily Health Policy Report
September 26, 2014

Underinsured ACA Enrollees Strain Community Health Centers

Obamacare enrollees are straining the finances of community health
centers around the country, some health center leaders say. The issue is
that many lower-income patients with insurance coverage through the
federal and state exchanges bought bronze-tier plans with lower premiums
but high deductibles, coinsurance and copayments and no federal
cost-sharing subsidies. When these patients face high out-of-pocket
costs for care that falls below the deductible, they can't afford it.
So the centers are subsidizing that care by offering them means-tested
sliding-scale fees. When the centers, which are not allowed to turn away
patients for inability to pay, try to get the insurers to pay, the
claims are usually denied, and the centers have to write it off as
uncompensated care (Modern Healthcare, Dickson, 9/25).

http://www.kaiserhealthnews.org/daily-report.aspx

****



Comment by Don McCanne

One of the advantages of reform that ensures that everyone would have
health care coverage is that safety-net institutions, such as community
health centers (CHCs), could be assured that payments would be made for
the services they provide, ending the continual struggle of funding
these institutions. As it turned out, reform will still leave 31 million
uninsured, perpetuating this problem. But at least those now insured
will no longer stress the budgets of the CHCs. Or will they?

Those purchasing the cheapest plans on the exchanges - the bronze plans
- have an average of only 60 percent of their health care costs covered.
This requires very high deductibles which are not affordable for many of
the low-income individuals purchasing these plans. Because of high
deductibles which are difficult to collect after services are rendered,
many health care providers are requiring payment upfront. Many would-be
patients end up walking away because of the lack of funds.

Where are these people to turn? The CHCs of course. They cannot turn
patients away, so they see them. When the CHCs then bill the bronze plan
insurers, the charges are below the deductibles and so the claims are
denied. They can then turn to the patients to try to collect
means-tested fees that would apply to the deductibles, but such efforts
are often futile, and so the CHCs end up writing off the charges as
uncompensated care.

This is the plight of the underinsured and of the providers who care for
them. With low actuarial value plans and often-inaccessible narrow
networks, underinsurance has become ubiquitous. It is one of the most
serious flaws in health care financing today, not only for the exchange
plans but now also for a rapidly growing percentage of
employer-sponsored plans.

This is just one of thousands of major flaws in our financing system. It
just isn't right. We can fix this by changing to a single payer national
health program. Let's do it. Now.