Monday, July 27, 2015



At some point you have to trust someone. Or not.

You have just received devastating news from your physician. You have a serious medical condition.

Scenario #1 – Your doctor suggests an aggressive course of treatment. Extensive and expensive. It might work. It might only give you a few extra months. But death is a certainty if you do nothing.

Scenario #2 – Your doctor advises you that all of the known treatments are painful, debilitating, and expensive. The likelihood of full-recovery is minimal, at best. He suggests palliative care and Hospice.

Do you view the doctor in the first scenario as a committed caregiver dedicated to doing everything to save your life or a shill for the medical industry prepared to profit from your illness and fear of dying? Do you view the doctor in the second scenario as a compassionate physician prepared to preserve the quality of your life or do you perceive a system that is prepared to sacrifice your well-being in an effort to save money?

Trust. Do you trust your doctor, your hospital, the insurance companies, or even the government? If you don’t, if you are positive that everyone involved is interested, first and foremost, in their own bottom line, than this discussion is over. There is nothing I can say that will change your mind or make an end-of-life discussion meaningful.

The balance of this blog is only meant for those with a healthy skepticism of our system and the players involved.

Medicine is an honorable profession populated by both the best and worst society has to offer. There are dedicated caregivers, committed claims staff, enlightened administrators, and elected officials prepared to do whatever it takes to make America safer and healthier. And there are people throughout the system who view the patient as either a profit opportunity or an unnecessary drain on our money.

There is no easy way to tell the difference, to know for sure that you are working with the right team. First you have to accept that there is a right team and that the system can work, that there are people up and down the chain who are willing to work on the patient’s behalf.

The Centers for Medicare and Medicaid Services (CMS) is again looking at physician reimbursements for advance care planning with their patients. Will doctors be paid for the time it takes to review all of the options open to their patients when they need this information the most, at the time of diagnosis and the beginning of treatment?

You may remember that this was a part of the Patient Protection and Affordable Care Act (PPACA). Those who choose to trust no one had their doubts. Some politicians called this “Death Panels”. This line of thinking works if you assume the worst of everyone involved.

But there is a counterbalancing argument. There have long been doctors and nurses who have questioned our end-of-life care. There are serious questions about whether average Americans endure more extensive treatments than similarly situated members of the medical profession. When is enough enough?

This blog, from its first post in 2009, has promoted adult conversations about healthcare and how we pay for it.

So it boils down to information. And trust. Mostly trust.



Monday, July 13, 2015

No, You Can't Do That

no you can't do that

Most of my clients are the owners of small businesses, really small. Lots of my guys have fewer than ten employees. When we talk about employee benefits we are discussing their money. Every premium increase is a direct hit on their bottom line. Some of my business owners are constantly trying to find new benefits they can provide to their employees and to their own families. In the small group environment, the boss has the same coverages, good or bad, as the rest of the employees.

Or not. For every business owner who plays by the rules and treats the employees fairly, there is at least one owner spending all of his/her time looking for corners to cut. Employee benefits may be the corner they love to cut the most.

There were very few rules in the group health insurance business up until recently.
  • Employees had to work full-time (25+ hours per week)
  • The employer could not discriminate.
  • The employer had to pay a substantial portion of the employee’s premium.
Ohio regulation stipulated substantial, but did not define it. Medical Mutual of Ohio interpreted that as 25%. The other major insurers defined this as 50%.

What you couldn’t do was pick and choose who got insurance or how much you, the employer, felt like paying per employee. Couldn’tt, but many did. And other employers reimbursed their employees for individually purchased policies or other health costs.

Those days are over.

The Patient Protection and Affordable Care Act (PPACA) clamps down on these practices. Enforcement is entrusted to the IRS who takes a dim view of these activities. Businesses with fewer than 50 employees are not required to offer group health policies, but if they do, they must be compliant. Employee reimbursement plans and other (not)groups are all lumped into the group category and deemed deficient. And the penalties are huge.

Such an arrangement fails to satisfy the market reforms and may be subject to a $100/day excise tax per applicable employee.

That’s a penalty of $36,500 per employee.

Is that excessive? Is that fair? Yes and Yes.

We always knew the right ways to do this. The employee should either have access to a real group policy or he/she should be responsible for purchasing an individual policy. Not every business can afford to provide group health insurance coverage. The employer may choose to give employees a raise with the hope, but not requirement, that the employee will use the extra money to purchase a policy. There can be no strings attached to the raise. The money is fully taxable to the employee and deductible to the business.

This is particularly important for those employees who might qualify for a Tax Credit Subsidy. Employees are generally not eligible for a subsidy if their employer offers a group health policy. Separating the real from the bogus may allow families to be properly insured. The small increase in annual income from a legitimate raise is unlikely to eliminate a subsidy.

If we agree that it is better to have all Americans insured, if universal access to health care is our goal, then we should welcome this new attention to the enforcement of the rules.