HEALTH CARE #7

Perhaps most of you think that the only federal government involvement in healthcare was limited to Medicaid, Medicare, the VA, or for those in the military. Surprisingly, there are many more healthcare programs in which our government has an intricate and affective involvement.

Besides:
1. Medicaid
2. Medicare
3. VA
4. Armed forces

There are and this is an incomplete list;
5. Indian and Native Alaskan Health Services
6. TRICARE
7. Centers for Medicare and Medicaid Services
8. State Children’s Health Insurance Programs (SCHIP)
9. EMTALA
10. Federal Employees Health Benefits Program
11. Diverse programs

Briefly the ones we think we know the most about follow;

MEDICAID: Medicaid; everyone knows it is a federally sponsored program for the economically deprived, who cannot afford healthcare. This is not quite true; Medicaid is a federally mandated program to be operated by the individual states.

In 2007 Medicaid spent $330 billion. The federal government supply approximately 57% of that amount. The rest is funded by the individual states. The Federal portion varies with different states being proportionally larger in the poorer states. Medicaid covers roughly 60,000,000 people, but still leaves 46 million uninsured. It is estimated that probably 18 more million could be picked up by changes in the program.

Under federal rules persons that must covered including children under the age of ix, pregnant women and those with family incomes below 133% of the poverty level, which is about $28,000 for a family of four in the states, Children from the ages of 6 to 18 whose family income is below hundred percent of the poverty level are also with the mandated coverage

The states are permitted to set their own rules on eligibility and the degree of required care. Most of the northern states are much more liberal than the requirements for Medicaid. In all states a great deal of services has been compromised because of present day economic conditions and the insufficient allotment from the federal government. That allotment is greater percentage wise to the states in poorer financial condition

A problem with Medicaid is the extremely low reimbursement rates, part of the problem that has made it unattractive to physicians except in a medical mill setting. These impacts on the quality of care. Institutions such as hospitals are often unable to meet costs at the level of Medicaid reimbursement.

MEDICARE; is tied into Social Security. It is limited to those over 65 or with certain disabilities that prevent employment. There are three separated programs; Part A, Part B. and the newest Prescription Medications.

Medicare part A: is the hospital portion. Those with over 40 quarters of accrued weeks of Medicare eligibility do not pay a premium; in 2009 those with 30 to 39 eligible weeks would have a monthly premium of $244.00 if below 30 weeks the monthly premium is 443.00. Both Plan “A” and “B” have deductible provisions.

Part B: is the Doctor, outpatient facility, and it is covered by a monthly premium that goes up annually, according to risks. In 2009 for a person over 90 it is over $190.00/month.

The individual can obtain the insurance directly from Medicare or through a commercial insurer plan such as an HMO. The later are under contract with Medicare to supply their service and receive government benefits to make their plan a profitable enterprise. They usually eliminate the deductable provision and any copayment due under “B”. The Government has encouraged HMO type commercial insurance at a lower rate.

Various supplemental insurance to cover deductibles and copayments can be purchased from commercial carriers including the “Blues”.

The PRESCRIPTION option is new. It is flawed by a deductible and a large gap when benefits have reached $2,700.00 and becomes effective again after $4350.00 where it becomes a catastrophic insurance with certain patient payment requirements. This insurance is sold by registered carriers and the policies differ in actual coverage.

A negative in these plans is the division of medications into 4 levels (the 4th is not covered) and the pressure on doctor and pharmacy to use generic drugs which may be classified as equivalent.

(note) In my practice years I often found that patients reacted differently to medications which supposedly had the same treatment capabilities and often to a named drug and another named drug or generic with exactly the same active ingredient but a product of a different producer. One such medication was " Synthroid" and "Levoxyl". and generigs as they arrived. All contained "levothyroxin" the manufacture could be controlled and the same amount assayed in each tablet- one source of variation in response to medications is even a slight difference in supplied amount per tablet. Other sources could be in the fillers. It was interesting that the two proprietary drugs remained constant in dosage response if the same brand was used but there could be no substitution.


Although the basic plans must contain the deductible and gap provisions, there is GAP insurance or supplementary available from various carriers at varying premiums and benefits.

(To be continued)

Health Care programs that have some connection to the Federal Government are so numerous that any blog report is bound to be sketchy and may contain some misinformation, there fore as we continue I welcome any and all corrections and additions.

HEALTH CARE (- 7a)

I had intended to post the second part of my presentation on Health Care programs or options. This was to be devoted to the Federal programs. To my amazement there is even more Federal involvement than those I have previously mentioned. A great deal more than Medicaid. Medicare, or Veterans Administration in the governments bag.

While I plan to have something in a cohesive format within the next 24 hours it may take longer since I am writing this series on the fly.

Meanwhile a few words on the reaction to some of the bloggers' opinion on the Roselle/Mapp incident.

So many of the ghosts who call themselves anonymous gloat that we who prefer Democracy and not a "Boss machine" government are desperate or expressing sour grapes because the local election turned out in what they call an overwhelming victory for JG.

The results can not be ignored, Nor can the fact that such a small percentage of the eligible party affiliated voters turned out to vote. Nor can the number of unaffiliated voters be forgotten for they may vote in November.

What does disturb me is the number of people who accept with glee the underhanded procedure that took place in Roselle. The methodology of ridding the "bosses" of an individual who stood up to them by abolishing their position CFO or Police Chief.

This nation is a Republic which is based on the principle of democracy. Democracy is defined as; a government in which the supreme power is vested in the people and exercised by them directly or indirectly through a system of representation usually involving periodically free elections. The government functions according to established rules (laws) and regulations. Any deviation is illegal unless proven otherwise.

The boss machine creates an Autocracy; a government in which one person (or group)possesses unlimited power. Even on a small scale of a municipality or county this has all the negatives of a dictatorship. Only scale makes a "Hague machine type" government differ from the power of a Fascist or Stalin state. Although this model claims to follow the same rules etc of Democracy, when ever the need arises it does not hesitate to create its own "rules' or unilateral abrogate the established ones.

Atogracy's disregard of the rights of others, often is the road to corruption. Ita supporters expect and tolerate such behavior.

We must make a choice every time we vote as to what we want. I for one find "Autocracy" in any form onerous. I would hope that everyone who celebrated the 4th would have the same opinion.

The heading is "Health Care" and I think it is not inappropriate since we are writing not about an individual but the Health of our Society

We have discussed the engines that drive the cost of Health Care. Now it is time to attempt to describe the various methods or plan s used to pay for those costs.

I will first try to give an overview of nongovernmental programs and then albeit incomplete the federal sponsored programs. After this it will be time to try to give pros and cons of various proposed solutions.

The problem facing America is how to extend affordable health care services to the approximate 70 million Americans who are either underinsured or have no insurance.

It is not clear if the uninsured number includes the “Illegals” who also burden the system. In most states the provider receives no compensation for their care. Therefore the burden is moved to those who pay for care and most heavily onto the uninsured but with some financial resources individual.

Briefly the modalities used by those who have some protection to pay for Health Care break down into the following groups:

Private individual insurance
Private Group Insurance
a) Service Compensation
b) HMOs
c) PPOs
d) POS
Concierge Plans
Federal
a) Medicare
b) Medicaid
c) VA
d) Indian Health Service
e) Military Health Services
f) TRICARE
g) EMTALA
h) Federal Employees Health Benefits Program

Private Individual Insurance plans are very expensive. The individual has no clout with the carrier and often there are strict limitations often in small print on the amount of coverage. Too often this type of protection exposes the individual to economic catastrophe. Many plans are of the Buyer Beware type.

Although many HMO, PPO, POS plans have provision for individual subscribers the premiums are much higher than those in a group plan.

Private Group Insurance Plans vary; all have in common that regardless of the plan group premiums are easier to actuarially determine and the larger the group the more clout it has in determining rates and provisions. Some plans have part of the premium paid for by the sponsor, for others it is completely the responsibility of the insured.

The benefits of the non HMO/PPO plans can vary from an extreme of minimal coverage to no limits. Here the principle of you get no more than you pay for applies.
The HMOs all are of the “gatekeeper” concept. The primary care physician is the key. These plans are of several types;

• The closed panel in which the individual selects his/her physician. All treatment, diagnostic testing, and specialist referrals must flow through the “gatekeeper” and may be restricted to only panel members. The patient has no choice of specialist or hospital. Any service rendered outside the panel is not covered. Most of these plans are “Facility” located. The Original “Rutgers HMO” was of that type and received heavy federal subsidence.

• The other plan was of the restricted panel type. The physicians and hospitals had a “contract” with the HMO sponsor (insurance company). The patient had to select a gatekeeper (primary physician) from the panel and was restricted to use only participating specialists and hospitals or surgical clinics in the panel. No non participating provider except in emergency would be paid by the HMO.

The primary care physician received a per capita per month reimbursement from most of the early HMOs; some were paid on a set for service base. The bigger the doctor’s panel was the more money he made. This led to briefer patient encounters because time and numbers was money.

The PPO plans at a higher premium permits the patient to choose specialist care often without the need for plan pre-approval. There was also freedom of choice of hospitals.

• Like the HMO the patient had to have a designated participating primary physician (the gatekeeper). Some plans had co-pay at this level. To limit ‘excessive” patient usage.

• The patient could use any participating specialist or hospital (Preferred Provider) after an approved referral by the carrier. There were specific co-pay provisions. Many of the participating physicians received a retainer fee based on the number of patients treated not visits.
• The patient could if desired receive a referral to a non participating physician after carrier approval. In those cases the patient would be responsible for the difference in its fee schedule and the physician’s charges.
• Thus the patient had a degree of choice.

The POS plans were more expensive. They are similar to the PPO in that after the patient had chosen his “gatekeeper”, he was free to use any \ specialist who had a fee agreement with the carrier. There would be a higher co pay involved. Referral usually had to be preapproved. In all cases the physician was paid on a fee for service which may have been negotiated beforehand, if not the carrier’s responsibility was limited and the patient would be responsible for the difference.

Various plans differ in the reimbursement to non-participating physicians and facilities. Co pay and deductibles differ in many of the plans. Again there is the matter of the small print in the contract.*

A relative newcomer to the field of Health Care providing is the so called “Concierge Programs. The principle is that the primary physician has opt out of any contracts with insurance carriers and now is free to set his fee based on the value of his service. Patients are given definitive appointments and there are no waits except foe unforeseen circumstances to see the doctor. The visit is adjusted to the needs not to a time limit due to mass appointments. The doctor is reachable 24/7, not an answering machine and a referral to the ER in an emergency. Many provide for house calls. There is usual a retainer fee paid to the physician and his panel will be limited to a serviceable number. This is a modified return with the exception of the retainer fee to the good old days.

Some plans cover everything done in the physician’s office, X-rays, EKGs, Laboratory studies, others limit the coverage.
Some insurance plans while not paying for the retainer will reimburse on their schedules for all other services.

There are several types;
• Fee for Service: The retainer is relatively small and the doctor charges a fee for his service based on time and problem.
• Retainer Service: The retainer charged is much higher but includes every service and visit normal to the Physician’s office including physical exams.
• Hybrid” There is still a retainer although lower and the physician accepts in full any insurance payment.

To continue

*Recent government legislation requiring the “small print” in credit card contracts to be easy to read, has not yet been extended to insurance contracts.

Format Changes

I was happy with my original format until I tried to post an email showing 10 pictures from the Hubble Space Telescope. Somehow everything on the right side was truncated so I had to change to a template that permitted everything to be reproduced. Unfortunately some had trouble opening the pictures.

I like this template that I am now using and hope you all also agree.

REPRISE-POLITICS THE DEMOCRATIC WAY

No I was not drunk. When I wrote "Politics the Democratic Way" July 4. There is much that I must learn about speech writing on the PC. Somehow between the time that I dictate and proofread, new words , sentences and other weird things appear. I have 30 days to read the manual- who does that- or otherwise decide this program is as useless to me as others have been.

I intend to remove that post from the face of this earth and repost it in the form taht I meant it to be. I hope that the 4th kept most readers from wasting time reading this or else if they did I hope they hjad a good laugh. This is the way it was suppoosed to read.

This is been a very unusual week regarding politics. Gov. Sarah Palin announced that she was resigning as governor of the Alaska. She and all of her family have been under personal attacks from members of the national Democratic Party and fellow travelers. Even her 14-year-old daughter was the subject of a tasteless Letterman joke . Her badly mentality/physically compromise Down Syndrome child as also been the subject of ridicule.

It may be perfectly acceptable for a public figure to become the object of ridicule and personal criticism, but the family especially young children should be exempt from such goings-on.

Spokespersons for the National Democratic Party have made it a practice of abusing others while hiding behind the first Amendment. This has often been a tactic at all lower levels.

At a local level Councilman Adrian Mapp has been twice the victim of the Organized County Democratic Party'swraith. It was not the voters of Union County that denied Adrian Mapp his second term as a freeholder, but the "party" that had not renominated him.

It was not Mapp's performance at the Freeholder level. There are probably less then 10% of the voters who know what a Freeholder's role is. Even less are aware of what a financial plum the position represents.

Instead, it was the aberration caused by the temporary control of the Democratic City Party in Plainfield by McWilliams and those who subsequently designated themselves as 'New Democrats" that has focused DeFillipo's cronies ire on Mapp. Mr Mapp entered politics as a friend of McWilliams an d it was during the honeymoon period prior to the old timers regaining control of the Plainfield City Committee that he was nominated and elected Freeholder.

During the recent primary campaign. Green posted a letter blasting Mapp from the same Roselle Council Woman who is a member of the shared services group that brokered the deal with Roselle Park. and a member of the Official Democrat Party. I do not know whether the elimination of Mr. Mapp's job in Roselle was part of an attack upon the borough's Mayor or punishment for Mr. Mapp seeking be the candidate in Plainfield for the Mayor. I would suppose both.

Despite DeFillipo reported statement that she has no time to be bothered in the local county's municipalities, her position and past record would suggest otherwise. Certainly, there are two short term ex-Mayors of Hillside both members of a citizen's reformation group, that might testify that their resignation from office was the result of political harassment.

Of course our local Chairman has not the power to impact on other area towns. November is only 3 months away. It will be interesting to see how our local politicians will align themselves in the coming general election at the local level and also at the State level. Will enough Independents and resentful Democrats unite to elected a New Mayor. Probably not but the race will be interesting.

TV FIREWORKS

Not the same as the smell of cordite. New York-Macy's was the most spectacular. Washington DC had the best ambiance,best performers and was the most impressive with the Washington Monument as center piece. What is missed is the old Boston Pops concert on the Charles with the 1812 Overture as the music for the finale.

Still a Holiday weekend,Check around noon time for an additional posting.

A happy Fourth of July.

This is a first. I am dictating using a program called Dragon 10 and I seem to have only had one wrong word typed in this first paragraph.

Noteworthy of the news this week was the coup in Roselle New Jersey where by a vote of four to two the Council voted to eliminate the chief financial officer position held by Adrian Mapp, and use the services of a part-timer supplied by Roselle Park. The Mayor of Roselle has been in political conflict with the Union County Democratic Party. Shades of Honduras or the New York State Senate or the election in Iran where there were more votes cast that were register voters.

The other interesting item was the judge's decision that the First Amendment did not apply to a blogger in protecting her source of information. I believe that this will soon be in the higher courts including the Supreme Court. In the meantime this is a landmark case

Nothing serious today just be careful and have a safe and happy fourth of July