Friday, January 11, 2019

Baby Steps




Health Care Reality – You don’t have any privacy and there really isn’t any such thing as transparency.

Your mail boxes are littered with privacy notices from your doctor, your insurance agent, and every enterprise that you have ever done business with, such as the banks and credit card companies. And you are eventually alerted, about six months after the fact, when they get hacked. Heck, they even throw in some free credit monitoring. The federal government is worried about the manila folders in my file room while Home Depot gives up information from 53 million Americans. And that is still less than the hacked Anthem database that included 78.8 million people.

Transparency would appear to be an easier problem to solve. After all, how hard is it to answer a simple question like, “How much does this test cost?” In truth, damn near impossible!

A recent article in the Kaiser Health News detailed, the new Trump administration mandated hospital pricing lists are hardly useful. The article discusses the difficulty someone would encounter in trying to determine how much an anticipated hospital stay would cost. There is no point in trying to price out an emergency. But, there are plenty of planned visits to the hospital. Wouldn’t it be nice to choose the most cost effective place to receive care?

So let’s start with the most important fact – None of these posted prices are real. These are the chargemaster rates, the rack rate, the price that the self-insured and uninsured would be charged. You are normally billed the negotiated fee, the price your insurer and the provided have negotiated. This contractual amount will often be a percent of the chargemaster rate and vary by insurer and/or institution. So, the number on the chart isn’t the number you will be charged. Worse, the pricing is per service, supply, and facility. An operation may include a charge for a number of rooms - operating, recovery, semi-private or private hospital room, plus, in certain hospitals, a facility fee just to walk into the building a breath the air. Doctors, sutures, and saline are all extra.

In honor of the administration attempting to do something positive, even if it is at best baby steps, I thought that we could look at one procedure, from one group of hospitals, just to get some idea of how this all works. I went to the Cleveland Clinic website and spent ten minutes trying to find anything. I will save you some time. The key word is “price”. Not “prices”. That will take you somewhere else. Below is the listed price, per facility, for a labor and delivery charge for one baby. There are different charges for twins, etc… “The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by your physician.”

Remember, these are all hospitals within the same system:
  • Akron General - $4,585
  • Avon Hospital – N/A*
  • Cleveland Clinic – N/A*
  • Euclid Hospital – N/A*
  • Fairview Hospital - $2,828
  • Hillcrest Hospital - $2,370
  • Lodi Hospital – No mention
  • Lutheran Hospital – N/A*
  • Marymount Hospital – N/A
  • Medina Hospital – No mention
  • South Pointe Hospital – N/A*
  • Union Hospital - $95.25 per hour
* N/A is really what they have posted as if there are no labor and delivery services available in these hospitals!

What do we learn from the price lists? Well, regardless of other services, if you can run in, give birth, and leave in 7 hours, Kate Middleton style, you should visit Union Hospital. Otherwise, not much. As their disclaimer states, this doesn’t include doctors, anesthesia, or even a chair for the father. We have to start somewhere. And this is what baby steps looks like.

DAVE

www.cunixinsurance.com

Picture – Baby Steps – David L Cunix

Saturday, December 15, 2018

He Doesn't Give A Damn



I was lamenting Friday night’s court decision in Texas. Across from me was a doctor, a really smart guy, who was not displeased. Upon prodding he finally agreed that many people, perhaps millions of Americans, might have reason to be concerned, but not him. After all, his side, the politicians whom he has aligned himself with due to both financial and philosophical reasons, had won. He could intellectualize the entire health care debate, but he didn’t see statistics much less people. Like most doctors in Greater Cleveland, he works for a system. The system handles all the dirty tasks of billing and collection and organizing the access to care. He just provides health care to whoever ends up in front of him. He just does his job. I don’t know if the system beat the empathy out of him or if he ever had any. I’m guessing he can turn his empathy on and off and thinks of people like us as leaky faucets. The struggle to preserve the access and payment for health care continues. My conversation with this doctor convinced me that he isn’t on our team, and that’s a shame. Like I said, he’s a really smart guy and we’re going to need all of the help we can get.

Healthcare.gov, the access point for millions of Americans to purchase individual health insurance coverage, was forced to send out announcements that the Marketplace was still open today, the last day of Open Enrollment. Forced. After two years of sabotage by President Trump and his administration, there was real fear that the portal would be closed immediately. Their site has a banner stating “Court’s decision does not affect this season’s open enrollment.” I received my first client email moments after the decision hit the news. Clients called the office to inquire about their status. They needed to be reassured that nothing has changed, yet. Welcome to America 2018 where governing by cynicism has given way to governing by fear.

This blog chronicled the run-up to the passage of Obamacare, the Patient Protection and Affordable Care Act. There were more than enough disappointments, pork-barrel politics, and short cuts to fill these posts and tick off my Democratic friends. And we have now had eight cynical years of the politics of repeal. (No links. Most of the last eight years have dealt specifically with this BS.) As long as we’ve had divided government the Republicans have had the luxury of whipping up their base, collecting large campaign donations, and the safety of impotence. It was a game that they thought, like Risk, would go on forever. But they won in 2016 and now have to govern and their actions have consequences.

What is at stake? What are some of the key consumer elements of Obamacare?
  • Guaranteed Issue
  • Preexisting Conditions are covered
  • No Health Screening – no penalty for previous illnesses or injuries
  • MEDICAID EXPANSION – coverage extended to the working poor
  • Tax Credit Subsidies – ongoing premium assistance that facilitates the purchase of coverage
  • Cost Sharing Reduction – a reduction in the deductibles and out-of-pocket expenses
  • Essential Health Benefits – compliant policies are comprehensive
  • No Maximum Benefit – elimination of the annual and lifetime limits
If you repeal the law without an alternative you eliminate all of the above and more. And what Republican alternative is waiting in the wings. It took seven years for Mitch McConnell and crew to give us the American Health Care Act (AHCA), last year’s half-hearted attempt at a replacement. There have been no public hearings. There has never been an attempt to craft serious legislation. There has never even been a serious attempt to improve and adjust the current law.

There was a decision last night in Texas. Americans are nervous. The president of the Federation of American Hospitals is clearly ticked off. The American Medical Association had filed a brief in defense of the law. President Trump has declared this court ruling a great victory. Of course he has.

DAVE

www.cunixinsurance.com

Picture – The Empty Field – David L Cunix

Monday, December 10, 2018

Beating The System




Open Enrollment season is coming to a close. The big challenge in Ohio is to pick the health insurance plan that will give you access to the doctors and hospitals you would want to utilize if you get sick or injured in 2019. If you are under age 65 in Greater Cleveland and paying for your own coverage, you only have one option to access the Cleveland Clinic, the Cleveland Clinic + Oscar plan. If you would like to get into the University Hospital system or Lake Health, you will choose Medical Mutual of Ohio. These policies are HMO contracts. Unless it is an emergency, you must use the doctors and hospitals in the system. Many of us have doctors in both systems. That doesn’t work. You must choose one system or the other.

This has put more than a few of us in a bind. Do you retain your cardiologist and find a new pediatrician for your kids? Which relationship is more important, the long held one with your psychiatrist or your comfort with your gynecologist? My advice to my clients is to choose the system, not the doctor. You can’t chase doctors. Not in Ohio.

As I’ve mentioned previously, I had a little health adventure in 2016. I took control of my care in early 2017 and put together a new team. A key member of this team is my oncologist. Great guy. He’s the one who orders the twice a year tests, including CT Scans, and then reviews them with me a week later. He always answers all of my questions. The last time we met I had one last question for him, a personal one. I wanted to know how he was doing since he seemed to be more focused on research than billable patient appointments. He assured me that he looked forward to our next visit in May 2019. I got a letter in the mail today from University Hospital that my oncologist had moved on and that the system would help me find a new doctor!

You can’t make a health insurance decision based on doctors. If you base your choice on doctors, you lose. You choose the system and find a doctor within it.

                    &                    &                    &                    &                    &

I had a pain my chest. It had bothered me for about a week. It might have been just indigestion, but I wasn’t sure. I could go to the doctor. I didn’t want to blow $50 or $100. I found out that my friend, Frank, had the same pain. I talked him into going to having it checked out. If it was nothing I beat the system and saved some money. The next day I heard that Frank had died. I rushed over to the Cleveland Clinic and got an executive physical. $2,000! They poked and prodded me and then told me that I was suffering from indigestion. I went to Frank’s house and asked his wife if he had suffered. She said, “No. He died the moment the bus hit him.” A Woody Allen classic updated slightly.

DAVE

www.cunixinsurance.com

Picture – David L Cunix – A Different Bus

Monday, November 19, 2018

Today's Question



It is Open Enrollment here at Cunix Insurance Services. In eight short weeks I will email or talk with close to 500 people. I have six to eight appointments in my office every day. And it really doesn’t matter if the visitors are twenty-two or seventy-two, married or single, self-employed or working for someone else, everyone has the same question – WHY IS THIS STUFF SO EXPENSIVE?

That is a good question. I wish the answer was as clear as the question.

It is important to remember that health insurance is a payment system. It is our way to organize the access and payment for care. If the insurance covers more care such as a colonoscopy as part of routine preventive care, maternity and mental health care the same as any other medical condition, and preexisting conditions, the price will be higher than if those costs were excluded. We appear, as a society, to have decided that these enhanced coverages are a good thing. We may not want to pay for them, but we aren’t prepared to go back to a time of more limited benefits.

Are the insurers jacking up the rates just because they can? The short answer is probably not. The Patient Protection and Affordable Care Act (Obamacare) includes the Minimum Loss Ratio. The MLR forces the insurance companies to spend 80 cents of every dollar on claims. The other 20% pays for all of their administration, marketing (including the agents), reserves and, if there is anything left over, profits. I’d like to push this onto the Anthems, Medical Mutuals, and UnitedHealth Cares of this world, but they may not be the biggest villains of this story.

The rising cost of care is the biggest driver in the rising cost of health insurance. That free colonoscopy isn’t getting any cheaper. Lifesaving treatments come at a price. And it is all too much until that is for you or a loved one. How much does that shot or pill cost? Medications seem to be a huge and growing factor in the cost of care.

Prostate cancer is a common condition for men of a certain age. A client and I were sharing treatment stories the other day. He was shocked that he was given an $18,000 shot. Been there. Done that. The medication in that shot has been around for thirty years, but they still get $18,000! Leslie Stahl’s report on 60 Minutes this week was on the price increases for medication to treat opioid overdoses. Major news organizations have been documenting the escalating prescription drug pricing for years. With little to no real action taken in Washington to curtail the price of medication, state legislatures are trying to fill the void, but it is an uphill fight.

This is November 2018 and the only thing I know for sure is that the price of your health insurance will go up for 2019. Most of my clients are seeing increases around 10%. My Grandmothered Anthem policy went up 26% and there is nothing I can do about it. It is a monthly reminder that we are all in this together.

DAVE

www.cunixinsurance.com

Picture – David L Cunix – Why?

Thursday, November 8, 2018

HOW?



The elections are over and most of the results are in. Most, but not all. A few races won’t be decided for several weeks. For good or ill, none of Ohio’s contests were that close. The winners can now begin to deliver on their promises.

The television ads for our new governor, Mike DeWine, were clear. Mr. DeWine may have had a checkered past in his defense of protecting affordable access to health care for Ohioans with preexisting conditions, but he is now prepared to champion their cause. We have his daughter’s word on it. It is time for all of us, in and out of the insurance industry, to ask “HOW?”

President Trump and his administration continue to work against one of the cornerstones of the Patient Protection and Affordable Care Act (Obamacare), coverage for Americans with preexisting conditions. The ongoing Texas lawsuit, supported by the president, is still a threat. Other actions taken last year, the defunding of the Cost Sharing Reduction and the elimination of the penalty associated with the Individual Mandate, continue to disrupt the health insurance market. And now, Mr. Trump has taken the next step to destroy your access to health insurance with new rules to allow the sale of stripped down policies.

We are looking at new rules that will make it easier to purchase short term major medical policies. These policies, which really do have a place in the market, are issued for a specific period of time, usually no longer than 6 – 12 months in duration. These policies are usually limited in nature, designed to exclude coverage for preexisting conditions, maternity, and mental health. If you push the young and, more importantly, the healthy to short term policies, then you are left with a health insurance system focused strictly on the sick and the responsible.

As an Ohioan, as an insurance agent, I wish Mr. DeWine luck. But it is time, Mr. DeWine, to tell us your plan. Protection for preexisting conditions? How?

DAVE

www.cunixinsurance.com

Picture – David L Cunix – At Least The Parking Is Free

Monday, October 29, 2018

Massaging The Message



I was lying face down on a massage table in the Beachwood Mall Comfort Zone. My lower back was giving me grief and this was the place to go. The place was packed. Every table and massage chair was filled. The shop does a good business, but there is normally one or two employees standing on the lease line asking for people to come in. Not today. Could this many people also have old basketball injuries? Exertion? Stress? Who knows?

Face down. My mind started to wander as he started to work his fingers into my shoulders. It certainly has been a stressful week. We were transfixed to our televisions as over a dozen bombs were mailed to a past-president and other government officials. Then there were the two elderly Black people executed at a grocery store in Kentucky. And then there was the horrific assault at the synagogue in Pittsburgh. I have been in that synagogue. Since it occurred on a Saturday morning, I was in a synagogue when the attack occurred. And if all of that wasn’t enough, we are less than two weeks from an election so the commercial breaks inserted between these terrible news stories were negative political ads.

Is he trying to pull my spine apart?


I thought about all of those ads. It seems like every candidate is claiming to be the number one champion of those of us with preexisting conditions. Every one of them. If that is the case, how come we’re so concerned? This is a good time to do the fire department test. Do you worry about the fire department coming out if your house was burning? Of course not! It is a given. Coverage for preexisting conditions is not a given. Our health insurance system prior to The Patient Protection and Affordable Care Act (Obamacare) offered little protection for those with chronic illnesses. Those guarantees are only five years old, not long enough to forget the way it was.

Is that his elbow in my back?

There are people running for reelection who have voted to repeal Obamacare over 60 times. That, in of itself, does not mean that they were unconcerned about preexisting conditions had they had a viable replacement. An actual repeal with an immediate replacement would have opened the door for a discussion on the merits of their proposal. But there wasn’t a replacement, a real, viable plan, was missing throughout the fight. From 2011 through 2016 we had grandstanding and campaign fundraising and votes, lots of votes, but no plans. Repealing Obamacare meant returning to a process that provided little to no security.

Repealing the PPACA wasn’t just the focus of the Republican controlled Congress. The governors and attorney generals from a number of red states attempted to have the courts declare the law unconstitutional. One case made it to the Supreme Court where Chief Justice Roberts was the deciding vote. Our current attorney general/ gubernatorial candidate Mike DeWine joined a lawsuit in 2011 to gut the law. This blog noted the current suit in Texas, supported by the Trump administration, designed to eliminate the coverage for preexisting conditions. Some of the litigants are running in their respective states as if their lawsuit didn’t exist!

Man that hurts! Deep Yoga breaths.

So how can many of our politicians claim to have any interest in protecting our access to care? The only possible answer is the 2017 American Health Care Act (AHCA). If you don’t feel like reading the entire bill, the link to the summary is here. Most people remember the AHCA because of the beer celebration at the White House after the bill passed the House and the late night votes by Lisa Murkowski (R-AK), Susan Collins (R-ME), and John McCain (R-AZ) that saved the country from this disastrous legislation. Did the AHCA provide coverage for preexisting conditions? Sort of. An amendment was included to “allow states to seek a limited waiver to allow the insurance companies to charge higher premiums for a person with a health condition only if they do not maintain continuous coverage”. How much? 30%! That and other holes would have doomed the law had there been the normal process with public hearings and amendments that we expect with any legislation, much less a bill that would impact 20% of our economy and our access to health care. But this bill was still better than nothing.

My half hour was over and it was time to pay and return to the real world. My back felt better but I couldn’t say whether it was due to the massage therapist’s efforts or 30 minutes without TV, Facebook, and the trouble we seem to be in as a country. One thing for sure, the therapist was certainly better at massaging my back then the politicians are at massaging their message.

DAVE

www.cunixinsurance.com

Picture – We all need a little Chutzpah – David L. Cunix

 

 

 

 

Sunday, October 7, 2018

Hide And Seek





November 4, 1995 was a warm fall day in Northeast Ohio. I was driving to Kidron to talk to some Amish craftsmen about a dining room table. I remember the day because that was when the news broke that Art Modell was moving the Browns to Baltimore. That next day, when I chaperoned a group of Cub Scouts to the game, was my last as a Browns fan. We have heard any number of reasons why The Move was necessary. But one excuse, briefly floated, was that the move would be good for the City of Cleveland, too.

We are witness to any number of self-serving actions that are sold to us as being good for everyone, perhaps even better for us than the obvious beneficiary. These actions might have financial benefits. These actions might have political benefits. Of course, sometimes the benefits are strictly entertainment, such as watching some politicians now trying to weasel out of their actions and votes over the last eight years.

Turn on the TV and marvel at the advertisements from Republican candidates for both State of Ohio offices and seats in Congress. Sure, they were voting to eliminate the Patient Protection and Affordable Care Act (Obamacare) last year with its guarantee of coverage for preexisting conditions. And no, there were never any alternatives that provided the same assurance that insurance, our method of accessing and paying for health care, would be available to anyone, regardless of health. But that is ancient history. Every one of them now supports coverage for preexisting conditions. Honest. Just don’t ask how.

This dissembling starts at the top. It was, after all, President Trump who said, “I will always fight for, and always protect, patients with pre-existing conditions” as his Attorney General Jeff Sessions argues that rules mandating the insuring of people with preexisting conditions and the guaranteed access to coverage are not constitutional. The cynicism of the last eight years has been taken to its illogical extreme.

Congressmen who were campaigning and fundraising last year on their personal mission to eliminate Obamacare are now running as the champions of the chronically ill and infirmed. I won’t link you to the commercials. And this is not an Ohio phenomenon. You can find this level of hypocrisy across the country. Some of the very same Attorney Generals mentioned in my last blog, Deep In The Heart(less) Of Texas, are campaigning on their concern for those with preexisting conditions.

It is important to remember that Mike DeWine and his cohorts really don’t want to throw sick people off insurance. They certainly don’t want to bar the poor and unhealthy from access to medical care. They don’t. They just don’t give a damn about how it gets done. They are sure that everything will work itself out. Meanwhile, being anti-Obamacare has been a terrific issue, a cash cow for fundraising, and gold at the polls on elections day. The very people who have benefited the most have, at times, been the most hostile to the law.

The Republicans have been playing Hide and Seek with preexisting conditions. And now, months before the 2018 mid-term elections, they have found the issue. But preexisting conditions have always been right here, in the middle of the entire health care / health insurance debate. It wasn’t that the issue was hiding. The Republicans simply weren’t looking.

DAVE

www.cunixinsurance.com

Picture – David L Cunix – Hiding in plain sight