S&S Benefits.....Opinion,
Hearsay & News Review
For all those who think estimates of the cost government
mandated health care figures are poppycock, you are right. They are gross
underestimations. From the Boston Globe the word comes that the original cost
estimate of the
Massachusetts
bipartisan health care mandated program would be $725 million with 215,000
people enrolled. The Globe reports that spending on the program will cost $1.95
billion this year. The state is now asking the federal government to help
shoulder half the costs. Take that into account the next time you hear any
political candidate say they are going to solve the healthcare problem and it
will only cost X. Riiiiiight!
The website of the Public Library of Science Medicine
says the lifetime costs for obese individuals and smokers are lower than for
healthy people that live longer. In a Netherlands study of 1000 people, on
average, the healthy lived 84 years with a cost of $417,000 for life while
smokers and obese people lived 77 years with lifetime costs
of $371,000 for the obese and $326,000 for smokers. Should we rethink
wellness initiatives with new programs such as Eat, Drink and Smoke and Be
Happy?
Unicare has announced that PHCS is taking over their
Rockford
,
IL
network and that customers should expect fewer docs to be available, but that
there will be greater hospital discounts. Also the Rush System for Health has
ended its participation in the Unicare HMO Illinois network. In addition Rush
Health Care System is no longer participating in the HealthLink PPO network.
UnitedHealth Group has completed its acquisition of Sierra Health Systems in
Nevada
. As a condition of the sale, the DOJ had UHC divest its individual Secure
Horizons Medicare Advantage group and those 25,000 members will be purchased by
Humana. NMHCRx is being acquired by SXC Health Solutions out of Lisle, IL. NMHC
will be treated as a wholly owned subsidiary and renamed informedRx.
Condell
Medical
Center
in
Libertyville
,
IL
continues talks with Advocate about being acquired. Condell has lost 20% of its
patient base due to terminating contracts with Blue Cross and they have had to
lay off 80 employees.
UNUM’s data indicates that LTCI is needed at a younger
age than most would think. Fifty-seven percent of Unum’s group LTCI claimants
are under age 65 with 15% younger than 45. More than 70% of under age 65
claimants received care at home.
CVS Caremark has settled (not admitting guilt) for $38.5
million with 28 states over charges of engaging in deceptive business practices
by encouraging doctors to switch patients to certain brand-name drugs where
rebates were better for the PBM. $2.5 Million will be set aside to reimburse
patients.
South Carolina has signed into law a bill a bill that
allows a group of at least 10 small businesses to join together to negotiate
less expensive insurance rates. The law replaces a law that no employers were
taking advantage of. That law required a minimum number of employees in the
group to be 1,000 when employers joined together for purchasing health
insurance.
Another New York Attorney General is trying to make a
name for himself. Andrew Cuomo says the AG’s office plans to file suit against
Ingenix, Inc. and its parent UnitedHealth Group over a scheme to defraud
consumers by manipulating reimbursement rates. Ingenix has for many years (they
bought out the database owned by HIAA) provided the Reasonable & Customary
(R&C) data to formulate payment rates for out of network providers.
(Apparently the concept of patients using non-balance billed networks escapes
government employee Cuomo). To explain: Ingenix gathers the data for all the
charges for medical procedures within a 3 digit zip code area from insurance
carriers and TPAs. The database is huge and usually updated every six months.
The charges are then broken down into percentiles. For instance, the 90th
percentile is what 90% of the doctors in a certain 3 digit zip code charge for a
certain procedure. The data Ingenix provides is then used by the insurance
carriers and TPAs to provide a U&C (or R&C, or U&P) rate for the
procedure. Non-network providers usually balance bill patients for the amount
over U&C.
Since most insurance plans reimburse out of network
claims at or above the Medicare level, perhaps Cuomo would be better off
suing Medicare for fraud? Medical providers who accept Medicare patients are not
allowed to balance bill them. If
Medicare reimbursement levels are appropriate, perhaps Cuomo might consider
whether a $200 fifteen minute office visit is overcharging by the physician? Is
that fraud? To accuse Ingenix of being guilty of fraud for supplying data would
be ludicrous. Government employee Cuomo illustrates again the fact that ignorant
government is not an oxymoron.