Showing posts with label failed insurance model. Show all posts
Showing posts with label failed insurance model. Show all posts
Tuesday, July 10, 2012
Taking A Risk To Secure Health Insurance
Taking A Risk To Secure Health Insurance
By Randy Dotinga
KaiserHealthNews.org
Henry J. Kaiser Family Foundation
JUN 12, 2012
When it comes to medicine, I usually do as I'm told.
Take a pill? Sure. Blood test? Absolutely. Surgery? If you think so, doc.
But I've been acting against medical advice since January, and I'll keep on ignoring it until July. Let me explain.
Last January, I cancelled my existing, very expensive individual coverage through California's state-run high risk plan and became insurance-free to gain eligibility for the federal alternative.
That means that if I get a cancer diagnosis tomorrow, I'll end up with huge medical bills. I did this because I want to take advantage of the federal government's efforts to help people like me who have pre-existing conditions and no access to a group plan.
Those two words -- pre-existing condition -- explain why I find myself in this circumstance.
Back in 1996, when I was 27, my heart started to beat funny. The diagnosis was lone atrial fibrillation, a kind of irregular heartbeat that appeared for no apparent reason and, in my case, couldn't be fixed. Even getting "cardioverted" didn't help.
A daily beta blocker keeps my heart from pumping too fast, and my risk of any complications is low. Even so, no one will insure me on the individual market.
And since I'm single and self-employed as a freelance writer, I don't have access to guaranteed group coverage, except for a plan for artists and writers that would cost me at least $31,226 a year.
That's why, for the last few years, I have made do with the state's high-risk insurance plan. California, where I live, is one of 35 states that offer health insurance to people with pre-existing conditions who otherwise wouldn't be able to get individual coverage.
But for me, access to California's high-risk plan is expensive -- the PPO plan would cost me $748 a month this year, close to $9,000 a year -- and the coverage is thin. The annual spending limit is just $75,000, hardly enough to cover a major health crisis. And the lifetime benefit limit is a paltry $750,000.
As a result of the 2010 federal health law, I now have another possibility: The federal high-risk plan would cost me just $265 a month -- $3,180 a year -- and offers unlimited annual and lifetime benefits.
That sounds like a great deal cost-wise, and the lack of coverage limits is much better for me in the long run if I get diagnosed with an expensive disease. But there's a rub: I'm not eligible for the federal plan unless I go six months without any coverage at all. That's just what I decided to do. To me, the prospect of affordable and unlimited coverage -- at least from July 2012-December 2013 -- is worth the risk of going without coverage for the allotted time.
"You're responding in an understandable way," said Harold Pollack, a University of Chicago professor who studies health care. "Any program that requires people to be actively uninsured creates a very paradoxical and painful set of incentives and encourages people to do what you're doing."
But I'm taking a major risk by going without insurance for so long. This would be the absolute wrong time to get hit by the proverbial bus. Or, as happened a few weeks ago, hear a dermatologist ask "Have you had that looked at?" while I lounge at a hotel pool. (Don't worry. I'd previously had it looked at, and it's nothing to worry about.)
My decision to go coverage-free did not go over well up in Sacramento when I mentioned it to staffers at the California Managed Risk Medical Insurance Board, which oversees the state and federal high-risk plans here.
A spokeswoman told me that the agency wouldn't cooperate with me on this story if I planned to embolden other people to make the same decision. Janette Casillas, the agency's executive director, put it this way: going without insurance in order to get insurance "is not something that we would encourage."
The federal government could change everything by getting rid of that six-months-without-coverage rule. But if it did, it would need to find another way to limit coverage for high-risk patients so it doesn't cost more than the budgeted amount, Pollack said. "They'd have to have some other rationing requirement that would also create problems, since it's such a small program for such a huge need," he said. "Almost every deficit of this program comes down to the fact that Congress has not appropriated enough money to meet the need that is there."
Even if I do land in the federal high-risk plan as of July 1 -- if space is available -- it's not a long-term fix for me or anyone else. The good news, for me at least: In 2014, the federal health law is scheduled to take full effect, including provisions that protect consumers who have pre-existing conditions from being denied coverage. The high-risk pool coverage won't be needed anymore.
Wednesday, January 4, 2012
Bad news: if your doctor won't stand up for you to your insurance company, you're in trouble
New Year, New Deals? Breaking Down Health Plan, Doctor Alliances
by Dan Diamond
California Healthline Contributing Editor
January 04, 2012
The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)
But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:
Out: Physicians and insurance companies as mortal enemies.
In: Health insurers and physicians ... as partners.
Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.
Are these deals an industry blip or the beginning of a boom?
Check back at year-end. For now, it's too soon to know.
The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.
Changes Afoot for Everyone
It's old news that industry players are taking on new roles.
Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.
But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.
Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.
"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."
What's Driving the New Partnerships
UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.
Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.
But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.
One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.
Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.
California at the Epicenter
These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.
What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.
A good share of these new physician-payer deals are unfolding in California.
That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.
CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.
Reaction and Reassessment
Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.
Monarch also leaves behind a pair of jilted ex-partners.
Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.
That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.
If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.
Here's what else to watch as the new year begins.
In the States
CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).
Challenges to Reform
After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).
Inside the Industry
Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models. After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3)...
by Dan Diamond
California Healthline Contributing Editor
January 04, 2012
The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)
But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:
Out: Physicians and insurance companies as mortal enemies.
In: Health insurers and physicians ... as partners.
Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.
Are these deals an industry blip or the beginning of a boom?
Check back at year-end. For now, it's too soon to know.
The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.
Changes Afoot for Everyone
It's old news that industry players are taking on new roles.
Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.
But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.
Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.
"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."
What's Driving the New Partnerships
UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.
Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.
But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.
One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.
Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.
California at the Epicenter
These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.
What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.
A good share of these new physician-payer deals are unfolding in California.
That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.
CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.
Reaction and Reassessment
Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.
Monarch also leaves behind a pair of jilted ex-partners.
Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.
That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.
If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.
Here's what else to watch as the new year begins.
In the States
CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).
Challenges to Reform
After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).
Inside the Industry
Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models. After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3)...
Friday, September 26, 2008
Default credit swaps: insurance or financial weapon of mass destruction?
Insurance makes us safer, right? Maybe not. Here's an article from Reuters.
Buffett's "time bomb" goes off on Wall Street
Sep 18, 2008
"...credit default swaps -- complex derivatives originally designed to protect banks from deadbeat borrowers -- are adding to the turmoil.
"This was supposedly a way to hedge risk," says Ellen Brown, the author of the book "Web of Debt."
"I'm sure their predictive models were right as far as the risk of the things they were insuring against. But what they didn't factor in was the risk that the sellers of this protection wouldn't pay ... That's what we're seeing now."
Brown is hardly alone in her criticism of the derivatives. Five years ago, billionaire investor Warren Buffett called them a "time bomb" and "financial weapons of mass destruction" and directed the insurance arm of his Berkshire Hathaway Inc (BRKa.N: Quote, Profile, Research, Stock Buzz) to exit the business...
"When the credit default market began back in the mid-1990s, the transactions were simpler, more transparent affairs. Not all the sellers were insurance companies like AIG -- most were not. But the protection buyer usually knew the protection seller..."
Buffett's "time bomb" goes off on Wall Street
Sep 18, 2008
"...credit default swaps -- complex derivatives originally designed to protect banks from deadbeat borrowers -- are adding to the turmoil.
"This was supposedly a way to hedge risk," says Ellen Brown, the author of the book "Web of Debt."
"I'm sure their predictive models were right as far as the risk of the things they were insuring against. But what they didn't factor in was the risk that the sellers of this protection wouldn't pay ... That's what we're seeing now."
Brown is hardly alone in her criticism of the derivatives. Five years ago, billionaire investor Warren Buffett called them a "time bomb" and "financial weapons of mass destruction" and directed the insurance arm of his Berkshire Hathaway Inc (BRKa.N: Quote, Profile, Research, Stock Buzz) to exit the business...
"When the credit default market began back in the mid-1990s, the transactions were simpler, more transparent affairs. Not all the sellers were insurance companies like AIG -- most were not. But the protection buyer usually knew the protection seller..."
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