You can look at this story in several ways. Walgreensis offering free health clinic visits to unemployed and uninsured individuals. According to the Associated Press, individuals and their uninsured dependents who become unemployed and uninsured after March 31 will be able to receive free treatment at Walgreen’s in-store clinic, which operates under the Take Care brand name. The typical visit costs $59 or more. Take Care’s lab partner, Quest Diagnostics, is helping out by offering tests for strep throat and urinary tract infections at no cost.

How you interpret this says something about your health care reform biases. Some will see this as further proof that the private sector can fill in the cracks of the safety net. After all, Take Care clinics are a for-profit entity. The press their receiving for this program and the positive word-of-mouth they’ll be receiving. Additionally, since the Take Care program provides free services for treatment that might otherwise wind up in an emergency room or urgent care center, they may make some sales of their other services such as immunisations or makes additional over-the-counter drug sales. So what they’re doing is an example of a market-driven win-win: consumers get care; Walgreens gets more customers.

The other perspective is that this effort highlights the cracks in the system. Newly unempl0yed who don’t qualify for government medical assistance through Medicaid or the State Children’s Health Insurance Plan (SCHIP) are poorly served by today’s system. Without employer based coverage and unable to afford individual insurance, they must rely on a drug store for their health care. There’s something wrong with that picture.

My take: Walgreens is to be commended for reaching out a helping hand to those who need it, even if they’ll profit from the gesture. And universal, portable and affordable health care coverage is needed and needed soon. The current system works well for most Americans, but as a nation it’s our culture not to leave anyone behind. The lesson here isn’t that we need a government-run system, but that we need a more comprehensive, integrated and sensible system to assure basic health care coverage to all Americans.

Posted in Health Care, Health Care Reform, Healthcare Reform Tagged: Medicaid, SCHIP, Take Care, Walgreens

As they said in the 60s, “you’re either on the bus or off the bus.” Were Ken Kesey talking in a more modern medical context he might have said “you’re either in the network or out of the network.” And being out of the network can be costly.

Unlike HMOs, which are closed systems — your health plan covers treatment within their network or, with few exceptions,  doesn’t cover the service at all — PPOs are more open. You get a higher reimbursement for seeing providers within the health plan’s network or you get reduced coverage for services from non-network physicians. The benefits to all concerned are rather straightforward: the physicians and other providers offer the health plan lower rates in exchange for the health plan encouring patients to see those providers. The health plan pays less so can offer their coverage at a lower cost, increasing their market share. Consumers pay less out-of-pocket when they use one of these preferred providers. Yet, if the consumer does seek medical care from a provider outside the network, the health plan pays a significant portion of the bill.

In theory, what the carrier pays for out-of-network services is a percentage of the usual, reasonable and customary (”UCR”) charges imposed by most providers in that community. That sounds fair: if a consumer chooses to engage a doctor who is more expensive than the norm, the consumer should pay for excess cost.

The problem is that few people know what the UCR cost is for any given treatment. Heck, physicians rarely know what the UCR is for their community for a particular service. When the carrier notifies the patient that their doctor charged more than what is typical it’s too late for the patient to do much about it. The result: angry patients, frustrated doctors and another deposit of ill-will in the industry’s karma account.

At the heart of the problem is defining “usual, reasonable and customary.” In the end, despite all the surveys and actuarial work,a high level of subjectivity is involved. How is it measured? Who determines if the costs are “reasonable” even if they are usual and customary. There’s a lot of wiggle room in the data base.

For years, the “decider,” as a past president would put it, for the nation’s largest health plans has been a company called Ingenix. Ingenix is owned by UnitedHealth Group, Inc., which also owns the health plan United HealthCare. Even though Ingenix is owned by a competitor, most of the major health plans in the country relied on its billing information for determining what out-of-network charges they would pay.

Not for long. New York Attorney General Andrew Cuomo went after Ingenixand UnitedHealth for manipulating reimbursement rates and defrauding consumers. As a result of Attorney General Cuomo’s actions, Ingenix will exit the billing database business and UnitedHealth will pay $50 million to help create a non-profit assigned to maintain a new, independent database.

While the New York legal action is no doubt painful to some carriers, most notably UnitedHealth, it could work to the industry’s benefit. It replaces a point of intense friction with an objective, common defintion. It’s not that the definition of UCR put out by the non-profit won’t still be significantly subjective — it will be. But it will be the definition of the non-profit.  And it’s not that consumers won’t blame the health plans when they disagree with the non-profit’s definition of UCR — they will. But the carriers will be able to refer their members to the non-profit.

Given the low regard the industry is held in by the public, any action which stems that flow of ill will deposits is a good thing.

Of course, this being America, the path to better karma is not an easy one. The industry will first need to go through the political guantlet of law suits and public hearings. Next in line: The Senate Commerce, Science and Transportation Committee.  It’s Chair, Senator Jay Rockefeller, is holding a hearing Tuesday in which executives from United HealthGroup and Ingenix will be the star witnesses. As reported by the Associated Press, Senator Rockefeller claims, UnitedHealth and Ingenix are “lowballing deliberately. They deliberately cut the numbers so the consumer as to pay more of the cost. … It’s scamming. It’s fraud.”

In that UnitedHealth has already paid $350 million to settle a suit on the matter brought by the American Medical Association, albeit without admitting guilt, the accusations are hardly surprising. And while UnitedHealth would like to put the UCR scandal behind them, there’s a script to these things and they tend to run through Washington. So this is just something they need to do. And it’s something they should do.

Because the UCR situation wasn’t fair to consumers. And if the industry needs to pay a price as part of fixing it, so be it. At the end of the day, there will be a more fair way of defining what out-of-network charges should be. And that’s a good thing for consumers, providers and health plans.

Posted in Health Care Reform, Health Insurance, Health Plans, Healthcare Reform, Politics Tagged: Andrew Cuomo, Ingenix, Jay Rockefeller, out-of-network, UCR, UnithedHealth Group

There’s a lot of moving parts when it comes to comprehensive health care reform. The goal is bring down the overall cost of care while increasing access to as close to universal as is possible. When you’re dealing with spending that amounts to $2.4 trillion, roughly 17 percent of the nation’s Gross Domestic Product, it can’t help be anything but complicated. (These figures are from the National Coalition Health Care’s web site). There’s so many moving parts involved and so many parties impacted by each proposal that it’s almost too much for any one person to grasp it all – assuming maintaining one’s sanity is a priority.

Fortunately the political process tends to winnow the complexity down to a few basic conflicts. Partly this is because many aspects of any reform proposal are noncontroversial (is there anyone who opposed promoting wellness?) In part it’s because the country’s 24-hour news organizations don’t handle complexity well. They next clear cut conflict to keep the commercials from running together. Pictures of Democrats and Republicans arm-in-arm singing the praises of cutting waste and fraud don’t garner viewers. Seeing them in a verbal cage match does.

One of the conflicts focused on during last decade’s health care reform debate was the creation of mandatory purchasing pools. The Clinton Administration proposed requiring all Americans to sign-up with these pools which would contract with private carriers to offer specified (meaning government determined) health plans.

Proponents of this “managed competition” approach argued it would lower costs, allow Americans to own their coverage without regard to their employment status, and force health plans to compete on efficiency and service. Opponents saw it as a government takeover of health insurance with HMO bureaucrats being supplanted by government bureaucrats in an effort to eliminate choice, increase government spending and eventually lead to a single payer system.

That was then. Now it appears the big fight will be over voluntary health exchanges. The idea here is that, if you’re happy with the health insurance you have, keep it. If you’re not, get your coverage from the exchange. That coverage, at least for now, is promised to be comparable to what members of Congress receive.

By having a horse in the race, so to speak, the government could assure a truly competitive market. Private carriers would be able to innovate and compete as they do now, but there’s be a new player on the field (to mix metaphors). That would prevent competition based on gaming the system and focus it on price, service, and meeting the needs of the public.

To advocates like former Vermont Governor and past Democratic National Committee Chair Howard Dean (who’s also a doctor) having a government alternative in the market is critical. According to Greg Sargent in his The Plum Line blog, Governor Dean is forming “Stand With Dr. Dean” to serve as a grass roots effort to push for inclusion of a public insurance option in whatever reform emerges in Washington. “We’re saying that if the public option is not included, it’s not real health care reform,” Sargent quotes a Dean-ally as saying.

At the same time, Republicans in Congress, most noticeably Senator Charles Grassley, the ranking GOP member on the Senate Finance Committee, is saying a government competitor in the market is unacceptable. As reported in the Wall Street Journal, opponents are concerned that if the government pool becomes too large, it will “drive down reimbursements to doctors and hospitals, much like Medicare does. To remain solvent those providers would need to increase the costs they charge private carriers forcing them to raise prices. Eventually this would force private carriers out of business, leaving only the government-run plan. In other words, creating a public plan creates a slippery slope leading to a single payer system.

Whether this scenario comes to fruition or not, there is a high likelihood that rules and regulations would emerge to benefit the public plan. To continue mashing sports analogies, when the umpire steps up to the plate, he’s rarely called out on strikes. Maintaining a level playing field could be impossible when one of the participants in the game is entrusted with setting and enforcing the rules. It’s worth noting that the Securities and Exchange Commission regulates stock markets, but it doesn’t sell stocks.

Whether or not there should be a voluntary federal health insurance exchange is an important issue, one of many important issues. It is rapidly becoming, however, one of the few defining issues of this decade’s health care reform debate. There will be others, but how this one is handled will say a great deal about the political process that will shape the ultimate health care reform package. If the debate over a public plan is civil and reasoned, it holds out hope for a compromise solution that takes into account multiple views. If a solution is rammed through Congress the hopes for bi-partisan health care reform will fade rapidly.

That’s the crux of the matter.

Posted in Health Care Reform, Healthcare Reform, Politics, Single Payer

Personally, I think health care reform is inevitable. The need for change is simply too great. Too many people go without coverage, too many are insecure about the coverage they have. Controlling medical costs is a critical part of fixing the economy: businesses and state and local governments need relief. Political pressure for a solution — from across the ideological spectrum — has reached critical mass.

The reform process is well underway. President Barack Obama held a health care summit at the White House earlier this month. Several proposals are making the rounds. Senate Finance Committee Chair Max Baucus has one.  Senate Health, Education, Labor and Pensions Committee Chair Ted Kennedy and his staff have been actively meeting with stakeholders. Democratic Senator Ron Wyden and Republican Senator Bob Bennett have one supported by 10 colleagues from both sides of the aisle. There’s the proposal put forward by President Obama during the campaign and embellished somewhat since his inauguration. Republicans have their plans and think tanks have theirs.

we’ve seen this before. In 1993 it looked like President Bill Clinton’s spent enormous political capital seeking health care reform. He failed. A recent Newsweek article by Katie Connolly outlined several reasons why the health care reform debate now is likely to be much different than the battles in 1993. The Clinton Administration failed in large part because their efforts were politically inept and inflexible. President Obama’s approach is much more open, inclusive and savvy.

Of course, at this stage we’re still dealing with generalities. The specifics, which is where the devil receives his mail, have yet to emerge.  When they do the hard part of the process begins. And that could be any week now.   The Washington Post’s Lori Montgomery and Ceci Connollyreported today that “House Democrats, in consultation with the White House, will give Republican lawmakers until September to reach a compromise on president Obama’s signature health-care initiative ….”  This means serious negotiations have to start sooner than later as the complexity of health care reform will require months of discussions to find common ground. And negotiations require specific items to negotiate over.

Finding common ground won’t be easy. Already Republican Leaders are identifying deal killers. A National Association of Health Underwriters’ newsletter quotes Senator Chuck Grassley, the ranking Republican on the Senate Finance Committee as identifying the Obama Administration’s call for a national health coverage exchange to compete with the private market as extremely problematic. The GOP won’t accept such a program, according to Senator Grassley, and Democrats are likely to insist on one. There may be a way to create an exchange that satisfies both parties, but that requires a lot more specifics than have emerged yet. 

There is a way for Democrats to pass health care reform without Republican votes. If a compromise fails to emerge by September, the House Leadership is pushing for a legislative process that would allow passage with simple majorities in both chambers. This would be accomplished through a process called “budget reconciliation.” Under the reconciliation rules, filibusters are not permitted enabling the Senate to move legislation forward with a simple majority of 51 votes instead of the 60 needed to end a filibuster. Democrats currently hold 58 seats in the Senate (including those of two independents who caucus with them) with one more likely to arrive from Minnesota. (Filibusters don’t exist in the House, making passage by majority vote the norm in that chamber).

But Democrats may have a tough time pulling together even 51 votes in the Senate. Senator Evan Bayh announced on MSNBC on Wednesdaythat 16 moderates in the Senate (15 Democrats and one independent who caucuses with the party) have come together to provide a united, centrist voice to issues such as health care reform. As noted in the press release announcing the group’s formation, their goal is “to pursue pragmatic, fiscally sustainable policies across a range of issues, such as deficit containment, health care reform …” and others. With 16 members, this caucus, currently dubbed the “Moderate Dems Working Group” represents more than a quarter of the Democrats serving in the Senate. If even 10 0f these centrists stick together they’ll need to be a part of any deal struck on health care reform.  (A list of the 16 Senators in the group is below).

At the same time there are liberals in Congress who would just assume have government take over the health insurance industry and create a single payer system similar to that in place in Canada and many Western European countries. At the very least they look to a greater role for the government in providing health care coverage to middle class Americans (the government is already the primary insurer for older and low income citizens).  They won’t go quietly along with a solution they feel fails to assure universal and comprehensive  coverage.

What this means is that while health care reform is coming, getting there won’t be wasy. But there is a way. President Obama has long talked of the need to focus on core principles and the desired outcome instead of on how we get there. He has even said that his campaign proposal for a federal health insurance exchange (the deal breaker identified by Senator Grassley) is negotiable. As noted in the Newsweek article, the president said at  the White House summit, ”If all Americans could be insured at ‘an affordable rate and have choice of doctor, have flexibility in terms of their plans, and do that entirely through market, I’d be happy to do it that way.’”

This is the approach all lawmakers and interest groups — whether liberal, moderate and conservative — need to bring to the table. The health care reform debate will be heated, passionate and difficult. But if all participants focus on the goals, the means of getting there can be found.  Given the need, it better be.

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The 16 members of the Moderate Dems Working Group (who, hopefully, will work on coming up with a better name) are:

• Evan Bayh (Indiana) - co-chair
• Mark Begich (Alaska)
• Michael Bennet (Colorado)
• Tom Carper (Delaware) - co-chiar and a member of the Senate Finance Committee*
• Kay Hagan (North Carolina) — a member of the Senate H.E.L.P. Committee*
• Herb Kohl (Wisconsin)
• Mary Landrieu (Louisiana)
• Joe Lieberman (Connecticut)
• Blanche Lincoln (Arkansas) - co-chair and a member of the Senate Finance Committee*
• Clare McCaskill (Missouri)
• Ben Nelson (Nebraska)
• Bill Nelson (Florida) — a member of the Senate Finance Committee*
• Mark Pryor (Arkansas)
• Jeanne Shaheen (New Hampshire)
• Mark Udall (Colorado)
• Mark Warner (Virginia)

* The Senate Finance Committee and the Senate Health, Education, Labor, and Pensions (H.E.L.P.) Committee have primary jurisdiction over health care reform legislation.

Posted in Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Bob Bennett, Charles Grassley, Clinton health care reform, Evan Bayh, Max Baucus, Moderate Dems Working Group, Ron Wyden, Ted Kennedy