September 9, 2013

The Affordable Care Act Part VI: Regulating Insurance and Consumer Protection

By Dr. Brian Carr
President, Behavioral Health Associates, Lubbock, Texas, 1991-Present
Chairman, City of Lubbock Board of Health, 2013
Submitted on September 9, 2013 - 8:01am

The ACA priorities are mostly focused on decreasing the number of the uninsured and the increasing consumer benefits. Probably the greatest weakness in the current law is the lack of regulation concerning cost containment.

Insurance carriers and big Pharma were brought on board with the idea of their being able to sign up 30 million new consumers. Consumers are at risk for increased costs due to there being more benefits and consumer protections. Insurance carriers are prevented from rejecting people because they have a pre-existing health condition. This is called “guaranteed issue”. This inclusion of consumers previously unable to obtain coverage will translate into high costs for the insurance companies with the resulting concern that they will simply pass this cost on to the larger pool.

While some of the regulations contained in the ACA reflect reasonable limit setting how the insurance carriers will manage these remains to be seen. New rules prevent insurance companies from canceling insurance policies for frivolous reasons (called “rescissions” in industry jargon) and requiring them to include “essential health benefits” in all their insurance plans.

Under another ACA rule, insurers must maintain tight “medical loss ratios.” MLR measures the share of their revenues that are devoted to medical benefits for policyholders. In 2012 insurance companies are required to spend at least 80-85 cents of every dollar on healthcare-not tied to such expenditures as administrative expenses, overhead or advertising.

The decision to establish a firm MLR is one of the better aspects of the ACA. Back in 1993, a time when many more non-profit insurers existed, the average MLR stood at 95 percent, meaning that the typical insurer paid out 95 centers of every dollar the company took in from premiums for the claims of policy holders. In the 20 years since that time, that level dropped to about 80 percent as non-profit insurers disappeared and Wall Street demanded more and more profit taking.

MLR (Medical-loss ratio) is very important to shareholders as it reflects the amount of money paid out in medical claims to premiums collected. Shareholders of health insurance companies look for changes in two measures: earnings per share, a standard measure of profitability at all publicly traded companies, and the MLR, unique to health insurers and always reported as a percentage. An MLR of 90 percent, for example, means the insurer spent 90 cents of every premium dollar on medical care. Since 1993, the average MLR in America has dropped from 95 percent to around 80 percent. By contrast, Medicare has consistently had a ratio greater than 97 percent since 1993.

Although Wall Street constantly pressures companies to reduce their MLRs, this imperative collides with the national standards, as established by the new health care reform law. Insurers are mandated now to spend at least 80 percent of premiums on medical care for the individual and small-group market (one hundred enrollees or fewer) and at least 85 percent for the large-group market. There is evidence that insurers are attempting now to “game” the system by “reclassifying” certain categories of costs than it had previously counted as administrative expenses and move them to the medical-spending side of the equation, effectively raising its ratios without making any actual changes in behavior.

Private health insurers abhor transparency and public accountability regarding claim denials, underwriting rules, payments to doctors and hospitals, death rates, racial or ethnic disparities in health status, or the health outcomes of their members. They are usually allowed to protect this important information as “trade secrets”.

From 2000 to 2008, insurers hiked premiums in employer-sponsored group health plans by 97 percent for families and 90 percent for individuals. At the same time, private-insurance payments to health care providers grew by 72 percent, medical inflation increased only 39 percent, wages only 29 percent, and overall inflation 21 percent. During these years, insurers raised family premiums 2.5 times faster than the rate of medical inflation, 3.3 times faster than that of wages, and 4.6 times faster than that of general inflation.

The lack of affordable, quality coverage has meant that many Americans with medical needs are driven to financial ruin. Medical debt was a key reason for 62 percent of personal bankruptcy filings in 2007. In 2008, there were 1.07 million household bankruptcies. This lack of coverage will contribute to the deaths of about 45,000 people each year, or 123 people every day.

The need for further regulation of insurance carriers operating under the ACA will be a major point of review in the coming years. Otherwise, the “shell game” of how premium monies are collected, administrative costs required, and profit margins will remain unclear.

To help consumers make judgments about health insurance carrier behavior the ACA will require health insurance carriers to, starting in 2014,

Submit to the Exchange, the Secretary of HHS, and the state Insurance Commissioner and publicly disclose the following information:

Claims payment policies and practices

Periodic financial disclosures

Data on enrollment

Data on disenrollment

Data on the number of claims that are denied

Data on rating practices

Information of cost-sharing and payments with respect to any out-of-network coverage

Information on enrollee rights

The new ACA MLR thresholds are already in place and many Americans may have noticed unexpectedly receiving rebate checks in the mail from their health insurance provider. In total, almost 13 million people have received about 1.1 billion from insurers who generated MLRs that fell below the new thresholds.

Next: The Affordable Care Act Part VI: Changes in Medicare

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http://lubbockonline.com/interact/blog-post/dr-brian-carr/2013-09-09/affordable-care-act-part-v-regulating-insurance-and

Cross-posted in Texas Group.

[font color=green]This is actually the sixth installment provided by Dr. Carr although the headline in the Lubbock Avalanche-Journal shows Part V. [/font]

September 9, 2013

Fan who fell to death at stadium during Packers-49ers game appeared drunk, police say

Source: AP

SAN FRANCISCO -- A football fan fell to his death from an elevated pedestrian walkway Sunday at Candlestick Park during the 49ers' final season opener at the San Francisco stadium, police said.

The death came just after kickoff at about 1:30 p.m. in the 49ers' 34-28 win over Green Bay, police said, and multiple witnesses reported the man appeared to be intoxicated before he fell to a sidewalk.

The death also happened the same day a railing collapsed at the Colts' game against the Raiders in Indianapolis injuring two fans who were leaning against the barrier above the tunnel leading to Oakland's locker room. It appeared both fans in Indiana escaped serious injury, stadium officials said.

In San Francisco, police spokesman Gordon Shyy said off-duty medics and police officers gave the man first aid until an ambulance arrived, but he was declared dead from his injuries. Authorities said he appeared to be in his 30s, and his name has not been released.

Read more: http://www.nola.com/sports/index.ssf/2013/09/fan_who_fell_to_death_at_stadi.html#incart_river_default

September 9, 2013

Potential 2016 hopefuls quietly court Romney money

Three years before the next presidential election, several prospective Republican White House contenders are quietly courting senior members of Mitt Romney's money machine.

For the candidates, Romney's team represents a well-connected group of influential donors who can quickly generate _ or divert elsewhere _ the financial resources that have become the lifeblood of modern presidential politics. The former Republican presidential nominee had questionable political skills, but his fundraising operation was considered an overwhelming success.

And Romney's fundraising lieutenants _ some new to national politics and others well-entrenched political players _ are beginning to look for a new home as the potential field of Republican presidential candidates grows. Some caution against reading too much into their early contact with candidates, but acknowledge that it's never too early to begin strengthening relationships with major donors.

"We built an interesting network of people. A lot of them would be inclined to get involved again," Romney finance chairman Spencer Zwick said in a recent interview. "I would love to be heavily involved."

More at http://www.theeagle.com/news/politics/article_76ca0ef6-6432-57e2-8558-7ab95c334f43.html .

September 9, 2013

Three Novels of the Texas Secession: Featuring President Perry, Russo-Texan Fighter Jets, and Col. J

Three Novels of the Texas Secession: Featuring President Perry, Russo-Texan Fighter Jets, and
Col. James Bowie Reborn

One is self-published, the others published by small presses. So you won’t be surprised to learn that these Texas secession-fantasy novels are full of anti-Democratic Party/socialist/United Nations paranoia. Their titles are Lone Star Daybreak, The Secession of Texas, and Yellow Rose of Texas. That last book is written by a pastor from Michigan.

None particularly sounds worth reading. Slate reviewer Kriston Capps writes that the authors ignore an actual revolution under way in Texas now:



More at http://frontburner.dmagazine.com/2013/09/06/three-novels-of-the-texas-secession-featuring-president-perry-russo-texan-fighter-jets-andcol-james-bowie-reborn/ .

September 9, 2013

Austin From Above: The Bird's Eye Views of Augustus Koch

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1873 bird's eye view of Austin by Augustus Koch

Among any city’s top tourist attractions are the views from above. A first-time visitor to New York will find time for a trip to the observation deck of the Empire State Building. Paris boasts the Eiffel Tower and London the London Eye.

But it wasn't always so. Before airplanes and skyscrapers came along in the early 20th century, aerial views remained in the imagination (or, for the lucky few, in the basket of a hot air balloon).

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1887 bird's eye view of Austin by Augustus Koch

Prussian immigrant Augustus Koch strove to change this. Not by erecting large buildings or inventing an airship, but by drafting accurate city views from the sky. Koch wasn't the only artist producing these bird’s eye views, but he was prolific and traveled widely, and fortunately for any 21st-century Austinite interested in exploring the city’s past, he drafted maps of Austin in 1873 and in 1887.

If you look closely at these maps, you can see some fascinating details about how life in our city was different in its early years.

More great images and current photos of the various buildings in Austin at http://www.austinpost.org/austin-history/austin-above-birds-eye-views-augustus-koch .

September 9, 2013

Toughest Man That Ever Lived? Texans - Remember Cabeza de Vaca

Question: who is the toughest man who ever lived?

I was talking to a group of friends when somehow we got on the subject of the toughest man of all time. One friend said "Muhammed Ali." Another said, "Chuck Norris." Still another nominated Aaron Rahlston, who famously amputated his own arm after falling in a hiking accident and having it pinned by a big rock.

Of course, I had to set them straight, telling them that, without a doubt, the toughest man who ever lived was Cabeza de Vaca.

Consider:

1) In June 1527, at the age of 40, Cabeza de Vaca left Spain for the Caribbean as second-in-command of a group of five ships with six hundred sailors. His captain was a man named Narvaez.

2) They overwintered 1527-1528 on the Caribbean island of Hispaniola (now Cuba). While there, they suffered a devastating hurricane and the desertion of 140 or so men.

-snip-

17) They walked into Culican early in 1536, 8 1/2 years after Cabeza De Vaca had left Spain, having traveled two thousand miles in less than two years, killing whatever they could more or less with their bare hands, eating desert plants etc...

18) Cabeza de Vaca reached Mexico City in July, 1536 and sailed back to Spain.

The entire account of Cabeza de Vaca's hardships are at http://www.austinpost.org/austin-history/cabeza-de-vaca .

September 9, 2013

“Shake-and-bake” meth making has a dangerous side

It is called “shake and bake,” a mobile method for making methamphetamine that is sweeping across the South and Midwest.

A more appropriate name might be “ticking time bomb” because of its explosive nature.

“It’s a really insane method of doing it,” said Jeff Moore, executive director of the sheriffs’ association in South Carolina, a hotbed for the portable meth labs. “Either you cook it and you get meth or it blows up and you get burned.”

Local law and drug enforcement authorities say evidence suggests that the latter is what happened last month when a flash fire in a car seriously burned five people in Lake Worth.

Read more here: http://www.star-telegram.com/2013/09/08/5144315/shake-and-bake-meth-making-has.html#storylink=cpy

September 9, 2013

Voting rights groups raise red flag

States and cities across the South, facing less heat from the U.S. Department of Justice over laws governing how their constituents vote, are raising alarms from voting rights groups as those jurisdictions propose changes that could turn back the gains minorities have won in the electoral landscape.

In Pasadena, a Houston-area community that has changed from being mostly a white refinery town to being almost two-thirds Hispanic, Ornaldo Ybarra, one of two Hispanic council members , said there is a “disconnect” between the community's Hispanic residents and City Hall.

He fears a recent proposal by Pasadena Mayor Johnny Isbell won't ease the problem.

Isbell surprised council members in July by announcing his support for a plan that would eliminate two council districts and replace them with two at-large seats. Council in a 5-4 vote also approved the measure, which will go to voters in November.

More at http://www.mysanantonio.com/news/local/article/Voting-rights-groups-raise-red-flag-4797595.php .

September 9, 2013

Texas pharmacy tied to outbreak holds inspection

CORPUS CHRISTI, Texas —

The compounding pharmacy linked to 17 bacterial infections at two Corpus Christi hospitals says it has found no evidence of contamination in its building or products.

The federal Food and Drug Administration recalled all products produced by Specialty Compounding of Cedar Park after reports of bacterial infections affecting the 17 patients.

Two patients died. But Texas health officials said previously they'd found no link between the recalled medication and the deaths of those who took it before the recall.

The Corpus Christi Caller Times reported (http://bit.ly/1fMH2BW ) Sunday that a representative for Specialty Compounding said the company hired a microbiologist to do its own inspection of the facility and to test samples — including swabbing the noses of pharmacists and technicians working there.

More at http://www.statesman.com/ap/ap/texas/texas-pharmacy-tied-to-outbreak-holds-inspection/nZqct/ .

September 8, 2013

Chris Wallace to Obama Chief of Staff: Where Are the Benghazi Arrests?

Following up on multiple questions regarding the proposed Syrian intervention and its fate in Congress, Fox News Sunday host Chris Wallace invoked the approaching one year anniversary of the attack on the U.S. consulate in Benghazi, and asked White House Chief of Staff Denis McDonough why the perpetrators had not been brought to justice.

Wallace was especially interested in why the U.S. had not arrested Ahmed Abu Khattala, who has been charged with the crime but not arrested, despite having given interviews to several news outlets.

“Why is it that reporters seems to be able to find this guy, who the government is charging with involvement in Benghazi, but law enforcement can’t find him?” Wallace asked. “It’s been a year, sir.”

You know what the United States does?” McDonough said. “We track every lead until we find and can accomplish what we do.”

http://videos.mediaite.com/list/recently_viewed/video/Bengazi090813

More at http://www.mediaite.com/tv/chris-wallace-to-obama-chief-of-staff-where-are-the-benghazi-arrests/