The Increasing Surge of Health Care

While sitting back in her blue jeans and wearing a heavy workout sweater at the Legacy Emanuel Hospital’s Emergency room, Angela Jones has her feet prompted up and crossed atop of a small table. When asked about health care issues and how they affect her, Angela explains that there is a portion of people who suffer from not having health care insurance. She makes it clear that some of those who suffer most are young people. Jones, who is a college student, declared her passion for the young because it falls under her own age group.

Says Jones, “The Oregon Health Plan should be open to more people who are under 21 years old. Private insurance shouldn’t be so expensive for young people.”

According to national surveys, the primary reason people are uninsured is the high cost of health insurance coverage. Notwithstanding, nearly one-quarter (23 percent) of the uninsured reported changing their way of life significantly in order to pay medical bills. Economists have discovered that increasing health care costs correlate to drops in health insurance coverage.

Jones believes that some of the greatest challenges that people face across this nation is obtaining affordable health care. “I would open an Oregon Health Plan to a variety of people who don’t have insurance. It is hard to get health insurance.”

Terri Heer, a registered nurse at a local hospital, claims that in order to improve America’s health care system a key ingredient is to “make sure that everyone (has) access.”

This would include cutting out on expenses that are not palpable to so called “health care needs”. Heer says, “First, we spend a lot of money servicing people for illnesses that can be prevented. Some of the money spent can go to other things.”

Over the long haul, should the nations health care system undergo significant changes, the typical patient may not necessarily see the improvements firsthand. “I would love to say there will be a lot of changes. I am not a pessimist, but I don’t think there will be any change,” says Heer. Heer does allude to the fact that if more money were spent for people in the health care arena, she says that there is a possibility that the necessary changes would be more evident.

Whether health care is affordable or not is an issue that affects everyone. According to a recent study last year, health care spending in the United States reached $2.3 trillion, and is projected to reach $3 trillion by 2011. By 2016, it is projected to reach $4.2 trillion. Although it is estimated that nearly 47 million Americans are uninsured, the U.S. spends more on health care than any other nation.

The rising tide of health care stems from several factors that has an affect on us all. First, there is an intensity of services in the U.S. health care system that has undergone a dramatic change when you consider that people are living longer coupled with greater chronic illnesses.

Secondly, prescription drugs and technology have gone through significant changes. The fact that major drugs and technological advancement has been a contributing factor for the increase in health care spending. Some analysts suggest that the improvement of state-of-art technologies and drugs increase health care spending. This increase not only attributes to the high-tech inventions, but also because consumer demand for these products has gone through the roof, so to speak.

Thirdly, there is an aging of the population. Since the baby boomers have reached their middle years, there is a tremendous need to take care of them. This trend will continue as baby boomers will qualify for more Medicare in 2011.

Lastly, there is the factor of administrative costs. Some would argue that the private sector plays a critical role in the rise of health care costs and the economic increase they produce in overhead costs. At the same time, 7 percent of health care expenses are a result of administrative costs. This would include aspects of billing and marketing.

Terra Lincoln is a woman who was found waiting in the Emergency room at the Providence Portland Medical Center. When asked about the rising costs of health care, she said, “If you don’t have medical coverage, it’ll cost you too much money. If I leave the hospital right now and I need to buy two (types) of medicines, I couldn’t afford it.” Lincoln says that she is a member of the OHP, but she believes that there are still issues that need to be addressed.

Terra recognizes that to reduce medical costs, she would have to start by getting regular checkups. “Sometimes people of color wait till they’re in pain before they get a checkup,” she said.

A national survey shows that the primary reason why people cannot afford health care is because of soaring costs of health care coverage. In a recent Wall-Street Journal-NBC survey it is reported that 50% of the American public claims that their highest and most significant economic concern is health care. Consequently, the rising cost of health care is the number one concern for Democratic voters.

Regarding the rising tide of health care, Kristin Venderbush, a native Wisconsin, and another patient in emergency at Providence says, “I worry a lot about what happens to the working poor. They don’t have OHP. If you can’t advocate for yourself, you will not get the health care you need…on every level.”

Harvard University researchers conducted a recent study that discovered that the out-of-pocket medical debt for an average consumer who filed bankruptcy was $12,000. This study noted that 68 percent of those who had filed for bankruptcy carried health insurance. Apparently, these bankruptcy’s were results from medical expenses. It was also noted in this study that every 30 seconds someone files for bankruptcy after they have had some type of serious health problem.

In spite of all the social and economic bureaucracy in the health care arena, some changes were made in Washington on January 28, 2008. In his State of the Union address, President Bush made inquired Congress to eliminate the unfair bias of the tax code against people who do not get their health care from their employer. Millions would then have more options that were not previously available and health care would be more accessible for people who could not afford it.

Consequently, the President believes that the Federal government can make health care more affordable and available for those who need it most. Some sources suggest that the President not only wants health care to be available for people, but also for patients and their private physicians so that they will be free to make choices as well. One of the main purposes for the health care agenda is to insure that consumers will not only have the freedom to make choices, but to also enable those to make decisions that will best meet their health care needs.

Kerry Weems, Acting Administrator of the Centers for Medicare and Medicaid Services, oversees the State Children’s Health Insurance Program, also known as SCHIP. This is a critical program because it pays for the health care of more than six and a half million children who come from homes that cannot afford adequate health insurance. These homes exceed the pay scale for Medicaid programs, therefore are not able to participate.

During SCHIP’s ten year span, states have used the program to assist families with low-income and uninsured children for their sense of well-being in the health care arena. The Bush Administration believes that states should do more of an effort to provide for the neediest children and enable them to get insurance immediately. The SCHIP was originally intended to cover children who had family incomes ranging from $20,650. This amount would typically include a family of four. According to sources, all states throughout the U.S. have SCHIP programs in place and just over six million children are served.

Children and Health Care

Washington’s Perspective

What is driving health care costs?

The fact that the U.S. faces ever increasing health care woes, has left many to believe that the country’s current crisis is on a lock-step path toward insolvability.

Article Source: http://EzineArticles.com/expert/Marcus_White/228562

 

Improve Your Well-Being – How Your Attitude to Health Can Help

What is Health?

How do you define health? Is it a state of complete physical, mental and social well-being? Is it merely the absence of disease or infirmity? Or is health a resource for everyday life, rather than the objective of living; a positive concept, emphasising social and personal resources as well as physical capabilities?

Good health is harder to define than bad health (which can be equated with the presence of disease), because it must convey a concept more positive than mere absence of disease, and there is a variable area between health and disease. Health is clearly a complex, multidimensional concept. Health is, ultimately, poorly defined and difficult to measure, despite impressive efforts by epidemiologists, vital statisticians, social scientists and political economists. Each individual’s health is shaped by many factors, including medical care, social circumstances, and behavioural choices.

Health Care

While it is true to say that health care is the prevention, treatment and management of illness, and the preservation of mental and physical well-being, through the services offered by the medical, nursing and allied health professions, health-related behaviour is influenced by our own values, which are determined by upbringing, by example, by experience, by the company one keeps, by the persuasive power of advertising (often a force of behaviour that can harm health), and by effective health education. Healthy individuals are able to mobilise all their physical, mental, and spiritual resources to improve their chances of survival, to live happy and fulfilling lives, and to be of benefit to their dependants and society.

Achieving health, and remaining healthy, is an active process. Natural health is based on prevention, and on keeping our bodies and minds in good shape. Health lies in balancing these aspects within the body through a regimen consisting of diet, exercise, and regulation of the emotions. The last of these is too often ignored when health advice is dispensed, but can have a pronounced effect on physical well-being.

Diet

Every day, or so it seems, new research shows that some aspect of lifestyle – physical activity, diet, alcohol consumption, and so on – affects health and longevity. Physical fitness is good bodily health, and is the result of regular exercise, proper diet and nutrition, and proper rest for physical recovery. The field of nutrition also studies foods and dietary supplements that improve performance, promote health, and cure or prevent disease, such as fibrous foods to reduce the risk of colon cancer, or supplements with vitamin C to strengthen teeth and gums and to improve the immune system. When exercising, it becomes even more important to have a good diet to ensure that the body has the correct ratio of macronutrients whilst providing ample micronutrients; this is to aid the body in the recovery process following strenuous exercise.

If you’re trying to lose weight by “dieting”, don’t call it a diet, first of all – successful dieters don’t call what they do a “diet”. A healthy diet and regular physical activity are both important for maintaining a healthy weight. Even literate, well-educated people sometimes have misguided views about what makes or keeps them healthy, often believing that regular daily exercise, regular bowel movements, or a specific dietary regime will alone suffice to preserve their good health. Despite the ever-changing, ever-conflicting opinions of the medical experts as to what is good for us, one aspect of what we eat and drink has remained constantly agreed by all: a balanced diet.

A balanced diet comprises a mixture of the main varieties of nutriments (protein, carbohydrates, fats, minerals, and vitamins). Proper nutrition is just as, if not more, important to health as exercise. If you’re concerned about being overweight, you don’t need to add the extra stress of “dieting”. No “low-fat this” or “low-carb that”; just healthful eating of smaller portions, with weight loss being a satisfying side effect. Improve health by eating real food in moderation. (For many reasons, not everyone has easy access to or incentives to eat a balanced diet. Nevertheless, those who eat a well-balanced diet are healthier than those who do not.)

Exercise

Physical exercise is considered important for maintaining physical fitness and overall health (including healthy weight), building and maintaining healthy bones, muscles and joints, promoting physiological well-being, reducing surgical risks, and strengthening the immune system. Aerobic exercises, such as walking, running and swimming, focus on increasing cardiovascular endurance and muscle density. Anaerobic exercises, such as weight training or sprinting, increase muscle mass and strength. Proper rest and recovery are also as important to health as exercise, otherwise the body exists in a permanently injured state and will not improve or adapt adequately to the exercise. The above two factors can be compromised by psychological compulsions (eating disorders, such as exercise bulimia, anorexia, and other bulimias), misinformation, a lack of organisation, or a lack of motivation.

Ask your doctor or physical therapist what exercises are best for you. Your doctor and/or physical therapist can recommend specific types of exercise, depending on your particular situation. You can use exercises to keep strong and limber, improve cardiovascular fitness, extend your joints’ range of motion, and reduce your weight. You should never be too busy to exercise. There’s always a way to squeeze in a little exercise, no matter where you are. Eliminate one or maybe even two items from your busy schedule to free up time to fit in some exercise and some “YOU” time. Finding an exercise partner is a common workout strategy.

Emotions

You may have heard about the benefits of diet and exercise ad nauseam, but may be unaware of the effect that your emotions can have on your physical well-being and, indeed, your longevity. Like physical health, mental health is important at every stage of life. Mental health is how we think, feel, and act in order to face life’s situations. Prolonged psychological stress may have a negative impact on health, such as weakening the immune system.

Children are particularly vulnerable. Caring for and protecting a child’s mental health is a major part of helping that child to grow into a normal adult, accepted into society. Mental health problems are not just a passing phase. Children are at greater risk for developing mental health problems when certain factors occur in their lives or environments. Mental health problems include depression, bipolar disorder (manic-depressive illness), attention-deficit / hyperactivity disorder, anxiety disorders, eating disorders, schizophrenia and conduct disorder. Do your best to provide a safe and loving home and community for your child, as well as nutritious meals, regular health check-ups, immunisations and exercise. Many children experience mental health problems that are real and painful, and they can be severe. Mental health problems affect at least one in every five young people at any given time. Tragically, an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide. A variety of signs may point to a possible mental health problem in a child or teenager. Talk to your doctor, a school counsellor, or other mental health professionals who are trained to assess whether your child has a mental health problem.

Control your emotions. If a driver overtakes you on the wrong side, or pulls out of a side road in front of you, don’t seethe with rage and honk your horn; You’re hurting no one but yourself by raising your blood pressure. Anger has been linked to heart disease, and research has suggested that hardening of the arteries occurs faster in people who score highly in hostility and anger tests. Stay calm in such situations, and feel proud of yourself for doing so. Take comfort in the knowledge that such aggressive drivers only increase their own blood pressure. Your passengers will be more impressed with your “cool” than with your irascibility.

If you are in a constant rush, feeling that every second of your life counts, just slow down a little. Yes, every second does count, but consider the concept of quality of life. Compare how you feel when you’re in a hurry with how you feel when you’re not. Which feels better? Rushing everywhere increases your stress level. The body tries to overcome stress by making certain physiological adjustments. Some time after you slow down, the physiological adjustments and the stress symptoms revert to normal. If you don’t ever slow down, the physiological adjustments and the stress symptoms persist. It is this persistence of the body’s response that matters. You may develop physical, physiological or psychological problems, and may not be able to lead a normal life. Many cases of stress are somehow connected with money, or rather the lack of it. Such people struggle to make ends meet or to acquire more material possessions. This brings us to our final discussion: attitude.

Attitude

It is always pleasant to enjoy the fruits of our labours, of course. Sometimes, however, it seems that whatever we do, it’s just not enough to be able to afford that new car or that foreign holiday. So, what do we usually do then? We work harder, longer; we increase the stress on our minds and bodies; we spend less time with our families and friends; we become more irascible and less likeable people. If you find yourself in this situation, just stop for a moment, and consider: Is it all worth it? What is the purpose of life? Surely it is to be happy. You’ll probably be happier if you adopt the philosophy that true quality of life is not to be found in material things. If you convince yourself that you want less, you’ll need less. If you need less, you’ll cope with life more easily, and the happier, and therefore healthier, you’ll be. Buddha called this “enlightenment”. Enjoy a “good-health attitude”. Focus on your abilities instead of disabilities. Be satisfied with what you have, rather than be dissatisfied about what you don’t have and probably never will have.

If you simply cannot cope with a healthy diet, exercise and emotional control, but genuinely prefer to eat junk food, be permanently drunk, be under constant stress, and be disliked by others, then enjoy your life while it lasts, but understand that the trade-off is that it will probably not last long. If you accept this willingly, you’ll be happy. There is some merit in the philosophy that it is better to live a short, happy life than a long, miserable one.

Conclusion

Personal or individual health is largely subjective. For most individuals and for many cultures, however, health is a philosophical and subjective concept, associated with contentment, and often taken for granted when all is going well. The evidence that behavioural factors such as diet, physical activity, smoking and stress influence health is overwhelming. Thus, health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society. Perhaps the best thing you can do for your health is to keep a positive attitude. Optimal health can be defined as a balance of physical, emotional, social, spiritual and intellectual health. Maintain a positive attitude!

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Group Insurance Health Care and the HIPAA Privacy Rule

HIPAA stands for Health Insurance Portability and Accountability Act. When I hear people talking about HIPAA, they are usually not talking about the original Act. They are talking about the Privacy Rule that was issued as a result of the HIPAA in the form of a Notice of Health Information Practices.

The United States Department of Health & Human Services official Summary of the HIPAA Privacy Rule is 25 pages long, and that is just a summary of the key elements. So as you can imagine, it covers a lot of ground. What I would like to offer you here is a summary of the basics of the Privacy Rule.

When it was enacted in 1996, the Privacy Rule established guidelines for the protection of individuals’s health information. The guidelines are written such that they make sure that an individual’s health records are protected while at the same time allowing needed information to be released in the course of providing health care and protecting the public’s health and well being. In other words, not just anyone can see a person’s health records. But, if you want someone such as a health provider to see your records, you can sign a release giving them access to your records.

So just what is your health information and where does it come from? Your health information is held or transmitted by health plans, health care clearinghouses, and health care providers. These are called covered entities in the wording of the rule.

These guidelines also apply to what are called business associates of any health plans, health care clearinghouses, and health care providers. Business associates are those entities that offer legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.

So, what does a typical Privacy Notice include?

  • The type of information collected by your health plan.
  • A description of what your health record/information includes.
  • A summary of your health information rights.
  • The responsibilities of the group health plan.

Let’s look at these one at a time:Information Collected by Your Health Plan:

The group healthcare plan collects the following types of information in order to provide benefits:

Information that you provide to the plan to enroll in the plan, including personal information such as your address, telephone number, date of birth, and Social Security number.

Plan contributions and account balance information.

The fact that you are or have been enrolled in the plans.

Health-related information received from any of your physicians or other healthcare providers.

Information regarding your health status, including diagnosis and claims payment information.

Changes in plan enrollment (e.g., adding a participant or dropping a participant, adding or dropping a benefit.)

Payment of plan benefits.

Claims adjudication.

Case or medical management.

Other information about you that is necessary for us to provide you with health benefits.

Understanding Your Health Record/Information:

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Legal document describing the care you received.

Means by which you or a third-party payer can verify that services billed were actually provided.

Tool in educating health professionals.

Source of data for medical research.

Source of information for public health officials charged with improving the health of the nation.

Source of data for facility planning and marketing.

Tool with which the plan sponsor can assess and continually work to improve the benefits offered by the group healthcare plan. Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy.

Better understand who, what, when, where, and why others may access your health information.

Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although your health record is the physical property of the plan, the healthcare practitioner, or the facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on otherwise permitted uses and disclosures of your information for treatment, payment, and healthcare operations purposes and disclosures to family members for care purposes.

Obtain a paper copy of this notice of information practices upon request, even if you agreed to receive the notice electronically.

Inspect and obtain a copy of your health records by making a written request to the plan privacy officer.

Amend your health record by making a written request to the plan privacy officer that includes a reason to support the request.

Obtain an accounting of disclosures of your health information made during the previous six years by making a written request to the plan privacy officer.

Request communications of your health information by alternative means or at alternative locations.

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Group Health Plan Responsibilities:

The group healthcare plan is required to:

Maintain the privacy of your health information.

Provide you with this notice as to the planâEUR(TM)s legal duties and privacy practices with respect to information that is collected and maintained about you.

Abide by the terms of this notice.

Notify you if the plan is unable to agree to a requested restriction.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. The plan will restrict access to personal information about you only to those individuals who need to know that information to manage the plan and its benefits. The plan will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. Under the privacy standards, individuals with access to plan information are required to:

Safeguard and secure the confidential personal financial information and health information as required by law. The plan will only use or disclose your confidential health information without your authorization for purposes of treatment, payment, or healthcare operations. The plan will only disclose your confidential health information to the plan sponsor for plan administration purposes.

Limit the collection, disclosure, and use of participant’s healthcare information to the minimum necessary to administer the plan.

Permit only trained, authorized individuals to have access to confidential information.

Other items that may be addressed include:

Communication with family. Under the plan provisions, the company may disclose to an employee’s family member, guardian, or any other person you identify, health information relevant to that person’s involvement in your obtaining healthcare benefits or payment related to your healthcare benefits.

Notification. The plan may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, general condition, plan benefits, or plan enrollment.

Business associates. There are some services provided to the plan through business associates. Examples include accountants, attorneys, actuaries, medical consultants, and financial consultants, as well as those who provide managed care, quality assurance, claims processing, claims auditing, claims monitoring, rehabilitation, and copy services. When these services are contracted, it may be necessary to disclose your health information to our business associates in order for them to perform the job we have asked them to do. To protect employee’s health information, however, the company will require the business associate to appropriately safeguard this information.

Benefit coordination. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with plan benefit coordination.

Workers compensation. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Law enforcement. The plan may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Sale of business. If the plan sponsor’s business is being sold, then medical information may be disclosed. The plan reserves the right to change its practices and to make the new provisions effective for all protected health information it maintains. Should the company’s information practices change, it will mail a revised notice to the address supplied by each employee.

The plan will not use or disclose employee’s health information without their authorization, except as described in this notice.

In Summary:

As an employee, you should be aware of your rights and feel confident that your employer is abiding by the guidelines of the Privacy Rule.

As an employer offering group insurance health care benefits, you should make your employees aware of their rights and should give them an avenue to obtain more information or to report a problem.

When you get your health insurance coverage through a broker that specializes in employee benefits, they should provide you with all of the necessary information and Privacy Notice to make sure you comply with the HIPAA guidelines.

Corinne Mitchell has worked in the insurance industry for 10+ years and currently works with the Group Insurance Benefits Specialists at http://www.nicoins.com

Read her blog [http://www.groupinsurancebenefitsspecialists.com/] for more tips.

Make sure you get expert advice and find the right coverage for you and your employees.

Article Source: http://EzineArticles.com/expert/Corinne_Mitchell/14230

 

A Prescription For the Health Care Crisis

With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.

But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

Please visit Dr. Lickerman’s blog at http://happinessinthisworld.com to read other articles about achieving health and happiness. He can be reached at alickerman@gmail.com.

Article Source: http://EzineArticles.com/expert/Alex_Lickerman/66934

 

Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ‘sleight-of-hand’ precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

– The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

– The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

– DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

– REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…

– REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

– PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

– PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Provider Fraud Consultants, Inc., dba Chiropractic Compliance Consultants, Inc., 18065 238th Street, Tonganoxie, Kansas 66086, 913-369-9000, [http://www.cccpfc.com]

Article Source: http://EzineArticles.com/expert/Daniel_J_Osborne/244604

 

Massage in Bucharest

Recognize it! You’re busy! And so must be! That’s what life is like! But you want more than that, you want to do more for yourself and massage can help. Because massage makes more than a simple relaxation of the mind and body. It keeps your body in shape and gives you enough energy to make you enjoy a longer life better than you do it today.

Massage releases stress. At the moment, stress is a universal evil. Every time you are late, every time you avoid a car in traffic, every time you have trouble working, stress is doing his job. Each time adrenaline increases heart rate and cortisone levels and organs respond to the measure. You will be in a state of nerves and constant agitation.
When there is no release of stress, serious problems such as an upset stomach, hypertension, sleep disturbances, chest pain, or existing illness may worsen.

Some of the changes that may occur are: Anxiety, lack of concentration, depression, permanent fatigue, muscle or bone pain, sexual dysfunction, excessive sleep or insomnia

All these stress-related problems can be diminished and some can be totally eliminated by massage. The researchers concluded that a massage session can lower heart rate and blood pressure, relax your muscles and increase endorphin production. The massage also releases serotonin and dopamine and the result is a general relaxation, both physical and mental.
Our body care must be at the top of the priorities.
By adding the massage to your routine you will look much better and you will be much healthier and relaxed. Massage can improve your vitality and mood. Massage can prepare for a long and beautiful life.

Our masseuses personalize each massage session according to the needs of the individual.
Our massage parlors offer a variety of relaxation styles and techniques to help you. Apart from relaxing, massage can be a powerful ally in reducing pain, increasing energy levels, improving mental and physical performance

We recommend : HotAngels , VipZone , JadePalace , ThaiPassion

After a massage session, you will see how the mental prospects are enriched, the body allows easier handling, better pressure resistance, relaxation and mental alertness, calm and creative thinking.
When you have the impression or force yourself to stay straight, your body is not actually aligned properly. Not only does the posture look bad, but it forces some of the muscles to go muddy all day, while others become weaker. After a long time, the incorrect position may cause other drops. For example, internal organs press on what affects digestion, breathing ability is also diminished, which means that much less blood and oxygen reaches the brain and hence all sorts of other complications.

Massage allows you to return your body to the track. Allowing the body to make healthy and accurate movements is one of the greatest benefits of massage. Massage can relax and restore muscles injured by bad posture, allowing the body to position itself in a natural, painless position.
Apart from posture, there is also anxiety. One of the signs of anxiety and stress can also be heavy breathing. When the body begins to breathe too little and deeply instead of breathing at a natural rithm, it is impossible for one to relax. One reason may also be that the chest muscles and the abdomen get tightened and the air gets harder.

Massage plays an important role in learning the body how to relax and how to improve breathing. Respiratory problems such as allergies, sinuses, asthma or bronchitis are a group of conditions that can benefit from massage. In fact, massage can have a positive impact on respiratory function.

Many of the muscles in the front and back of the upper part of the body are breathing accessory. When these muscles are tight and shorten they can block normal breathing and interrupt effective breathing natural rithm. Massage techniques for stretching and relaxing these muscles improves breathing function and breathability. Massage leads to an opening of the chest as well as structural alignment and nerve dilatation that are required for optimal pulmonary function. A good way to treat respiratory problems with massage is the taping made in Swedish massage. When done on the back, along with vibrations, it can detach the mucus from the lungs and can clean the airways for better later function.

Massage not only relaxes muscles, but helps people become aware of daily stress levels. Once the body recognizes what really means relaxation, the mind can rest easily relax before the stress becomes cornice and harmful. This will help you enjoy a balanced life. Massage controls breathing, allows the mind to re-create relaxation before the occurrence of chronic and harmful stress and increases the level of energy.