Gaston Rehab Associates, Inc. Physical Therapy and Sports Performance

North Carolina Patient Access to Physical Therapy Care

Every day patients go without the care they need in order to reduce pain, increase strength, improve mobility, and regain their life back because they can not afford their Physical Therapy Co-pay/Co-insurance. Right now in the State of North Carolina Physical Therapists are considered specialists and patients are responsible for a larger "specialist" Co-pay in order to receive the services. Many times patients have a $40, $50, or even $70 Co-pay with a commercial insurance plan. That is on top of paying their monthly premiums. If the Physical Therapist is paid $55 for the session and the patient paid $50 or more this is no longer a Co-pay and is now a "paid in full" service. If someone needs 2-3 visits per week in order to meet their goals and is seen 10-12 visits this adds up quickly. If you or a loved one has a stroke, an amputation, or a head injury from a car accident or a gun shot wound the care plan will be much longer and even more expensive.

Something needs to change and we need to make it so that Physical Therapy services can be accessed at the primary care provider Co-Pay/Co-Insurance rate in the State of North Carolina. This is about letting patients get the care they need at a price they can afford and about making insurance companies pay for the services they say are provided in their network of care. Please sign this petition to let the State of North Carolina know that you are not going to settle for this any longer and that legislation needs to be passed to make this law and not a policy from the Insurers.

To sign the Petition please go to the following web site:

http://www.change.org/petitions/north-carolina-patient-access-to-care-for-physical-therapy

Accountable Care Organizations: Are they the next pain or are they progress?

Acountable Care Organizations (ACO) are the new buzz word in healthcare. While it makes sense to want to decrease spending and lower costs on healthcare, the proposed model if not set correctly could place greed before actual results.

Hospitals are fighting for the opportunity to become the ACO as it would place their services and providers in the spotlight and sustain their business model. The problem is that it also sets up an opportunity for a monopoly of services and reduces community collaboration and competition which in the end ultimately drives down the cost of care.

My vote is to have the federally funded health centers be the ACO as our tax dollars are already going there and their model of community collaboration would fit nicely in this proposed system.

MedPAC actually gets it right. Anyone listening?

The Medicare Payment Advisory Commission  (MedPAC) may have finally made some recommendations which make sense. Now whether anyone in Congress chooses to listen is up for debate.

In a press release dated Feb 29, 2008 MedPAC concluded:

...that the Congress and CMS will need to make changes across a broad front to increase quality, slow the growth in Medicare expenditures, and address Medicare's long-term sustainability.

Among the findings was a call to update the physician fee schedule (amount that Medicare pays for services provided).

An update equal to the increase in input prices less MedPAC's adjustment for productivity growth. (The ten year average of productivity gains in the general economy, 1.5 percent for 2009.)

Unfortunately the sustainable growth rate (SGR) formula has been in use for some time and calls for substantial negative updates (decreased reimbursement levels) through 2016. The Commission states:

[We are] concerned that annual cuts would threaten beneficiary access to physician services over time. In addition, the Congress should enact legislation requiring CMS to establish a process for measuring and reporting physician resource use on a confidential basis for a period of two years.

Unfortunately this is what we have been trying to say for years. You cannot expect to provide quality health care with less reimbursement. Now if we could only get all of the private health insurance companies to come up with the same findings, we might be on to something.

Universal Health Coverage

As if we needed another example of why Universal Health Coverage in the US is not a good idea.  A great example of why a one payer system in Canada can cause more trouble than it is worth is shown in this short movie clip. A man from Canada starts having headaches and seizures and as most would suspect, he believes he has a brain tumor. A normal course of diagnosis would be to have an MRI or a CT Scan immediately. He was told he would have to wait 4 months. Even as he begged to pay for it on his own, he was told "no" that he had to wait. What did he do? He went across the border had the MRI in Buffalo, NY found out that he indeed did have a brain tumor, stage 2 astrocytoma, and returned to his own family physician with the proof. He was told that it would take another 4 months to get in to see a neurologist to plan what to do next.

Wow, how much damage can a cancerous tumor do in 4 months? Fortunately this gentleman didn't have to find out. He returned to the US and had the tumor removed. The only problem he was left to pay the $28,000 bill out of pocket. Small price to pay for your health, but all of this could have possibly been avoided if his "insurance" would have allowed for a more timely diagnosis and treatment in his own country.

While I do not believe that health insurance in this country should be "for-profit," I do believe it is better than Universal Coverage. I am a big proponent for "non-profit" insurance companies that would reinvest their profits back into research or even into a pool to cover the under-insured if necessary.

I would also do away with insurance companies who first and foremost answer to their investors rather than their members. I believe that paying members who are insured should be investor enough. Why can't health insurance companies pay "dividends" back to members that pay their premiums? Those individuals who actually take care of themselves and whom do not drive up costs by making poor lifestyle choices? To me those are the real investors in insurance companies. Of course that would make too much sense and probably wouldn't be good for business. Imagine an insurance company surviving trying to take care of healthy people?

Looking inside UnitedHealthcare

I was pleasantly surprised when I opened the newsletter from United Healthcare today. The following almost brought a tear to my eye (and then I got over it when I kept reading)

UnitedHealthcare is committed to transparency and to improving the service we provide to physicians and other health care professionals.  As part of this commitment, we have developed a new online tool that allows physicians and their offices to track our performance on several key administrative initiatives - the UnitedHealthcare Scorecard.

I am still not convinced that this will help to improve the reimbursement rate or do much to help with affordable insurance, however I do believe it is a step in the right direction and one that I wish more companies would follow. I believe transparency would do a lot to reduce the healthcare crisis that we will soon face if things continue on status quo.

What other insurance company would like to be next?

 

Imagine

Aetna President Mark Bertolini in a recent presentation to business leaders and lawmakers commented that health insurance should be required for everyone. Noble, however he goes on to add that the system should be a private-public joint venture and not a single payor system as some have proposed. He also goes on to add that there needs to be a reduction in mandates for healthcare coverage existing in the state laws.

So let me get this straight, Mr. Bertolini is asking for a mandate that his company will most likely benefit from, followed by a call to reduce the number of mandates in state law regarding insurance. Sounds to me like Mr. Bertolini is truly an insurance company representative (he must have had the same people that write the Aetna insurance policies write his speech) with a good start on his next career, running for Congress.

Transparency in Healthcare Prices as a Solution?

According to a recent study by the Kaiser Family Foundation and Health Research and Educational Trust, premiums for employer-sponsored health insurance rose an average of 6.1% in 2007. Now this was less than the 7.7% increase in 2006, unfortunately both are still higher than the increase in the average workers' wages (3.7%) and the overall inflation rate (2.6%).

This is almost appalling that we continue to allow this to happen. Insurance companies are big business and answer to stock holders first and foremost. Even in NC where BCBS is supposed to be a public company, they are allowed to retain their earnings. So if premiums continue to rise at the current level of 3 to 1 with inflation and 2 to 1 compared to wage increases the average person will no longer be able to afford health insurance in their life time.

Now one problem is the issue of entitlement that is plaguing our society. The founders of our great country were in no way implying that the pursuit of happiness and freedom included entitlement to the best healthcare available and free of charge. What happened to paying what was fair and in turn making an honest wage? Unfortunately there are too many people that expect to have the best care and not have to pay a dime and then there are those on the other side of the fence that got into healthcare (including insurance) looking to make all the money in the world.

So back to entitlement, could this be the downfall of the current system? I believe it will be. In the days before the HMO's in the early 80's, insurance fraud was rampant because of too little checks and balances. Healthcare providers would charge whatever they wanted to charge and the insurance company would pay it. Also people utilized the healthcare because it was available and often times necessary. So insurance pulled the reins, pulled back on what they would pay and healthcare providers started complaining. They said technology costs and we need to keep making more money too.

Technology does cost and the cost of the new technology is being passed on to the patient. But how often do we know about? If the insurance company decides they are not going to pay for a service then the person has to pay for that service. I wonder how many of us would drive across town to a physician that charged only $70 a visit as opposed to the one across the street that charged $150 a visit that was no better than the one across town? How about an MRI that cost $845 vs $1000 at a center in another town?

Transparency in healthcare billing is not new, but very few offices practice such a thing. When we opened our office three years ago we had a therapist with many years of practice ask if we considered doing the unthinkable; being tranparent with our costs/billing. I had never really thought about it because no other place I worked had done such a thing. To be honest the thought of "transparency" in which we opened up for all to see what we charged was not only foreign, but scary as well.

After three years, I can honestly say it was one of the best things we could have done. We still have people that do not want to pay. Those are the same people that will try to get a $.99 hot dog for free and will take advantage of any situation.  And then we have people with the best of intentions on paying, but for one reason or another just can't make ends meet when it comes time to pay. But overall, if you come into our office after every visit we tell you what you are getting charged for, provide you with a receipt of those services and then instruct you to watch for your explanation of benefits (EOB) or explanation of payments (EOP) from your insurance company to make sure they match up. You will also generally get a rough estimate of what it will cost you if you have a co-insurance rather than a co-payment. And no one has ever complained about us taking this additional couple of minutes at the end of the treatment session. What this does, is it allows our clients to realize upfront if they can afford our services. If not, we can look at options to still get them the care they need and it gives us a place to start.

If every healthcare provider started to do this, much like any other industry, those truly outstanding facilities and providers would still be able to make money and charge at a higher rate because their value would be seen and clients would have no problems paying. It would also help to either drive out or at least force those other facilities not to do as well financially for providing lousy service or treatments. It would also force some friendly competition and keep costs lower on a whole because others would see what they were charging. Much like gas stations, they will generally keep their prices within a few cents of each other if not exactly the same and everyone usually benefits.

To put it in perspective think about the last time you had a hamburger at a restaurant. Chances are if you went specifically to that restaurant looking for that hamburger it was either because of price or taste or both. If you could consistently get a good hamburger at a fair price chances are you would go to that place again. At least you could make a choice based on either price or feeling that you got from that burger.  But suppose the menu had no prices. Suppose you ate the hamburger and then were presented a bill afterward. You were hungry and needed to eat, so if the bill was for the price you were used to paying you would have no problems. What if you had never eaten a hamburger out before though. Say you had alwasy eaten hamburgers at home and knew how much you paid at the store, but did not know what to expect the price to be at the restaurant. Now say you were presented with a bill for $600 for that hamburger. You already ate, so now you owe the $600. This could become even more complicated if this was the only restaurant in town and all the grocery stores were closed. If you knew the hamburger was going to cost you $600 you probably would not have eaten it and you would have either made the choice to go hungry or try something else. At least you could make the choice.

Such is not the case in most instances with healthcare services. When was the last time you walked in and a price list was mounted on the wall for the procedures? Even a mechanic will give you an estimate. I believe there needs to be transparency in healthcare costs and billing procedures and only then can consumers make educated decisions about the services they seek and the services they decide to receive. Think large hospitals and healthcare providers can't do this? If the Hilton Hotel chain can price things in their mini-bar differently across the world, then even the largest hospital can do the same. And they already are, they just are telling you what they charge.

Consumers Guide to Health Insurance

The following publication, provided by the U.S. Department of Health and Human Services, is a well designed guide for the consumer to educate on the basics of healthcare coverage.

http://www.ahrq.gov/consumer/insuranceqa/

Cigna back in the news

Cigna has forecasted to have another increase in profits for 2008. Now one might look at this and say that well it is because of an increase in membership. Unfortunately I am not sure that any insurance company needs to have a profit of $780 million while premiums keep going up and employers are forced to pass more of the financial pain onto their employees.

http://www.reuters.com/article/marketsNews/idUKWNAS014520071102?rpc=44

I believe it would be more responsible for the big insurance companies to reduce their profits and keep premiums at the same level for one or two years in order to allow for members to benefit. Unlikely since stock holders expect to see results and dividends for their investment in these private insurance companies.

One good thing that could come from this is that I doubt we will ever see a socialized medicine system in the US. The concept of a united socialized medicine system is like the concept of trying to make an NCAA Division I Football Playoff. There is more money to be made from each individual insurance company just like each individual bowl game (or at least that is what those making the money want to believe) and I would believe that insurance companies with deep pockets would and will fight tooth and nail to never allow such a system.

Healthcare Coverage and Unions

The UAW and GM have reached an agreement to end the strike. The only thing is, how will this resolve the issue of healthcare coverage for all employees including retirees and their families?

http://www.lsj.com/apps/pbcs.dll/article?AID=/20070926/NEWS03/70926007/1004

By developing what is called a VEBA (Voluntary Employee Beneficiary Association) the UAW would take control over the healthcare benefits of its members and release the burden from the "Big Three" (Chrysler, GM, and Ford). Funding would come from the automobile manufacturers themselves, but they would be placed in an account and the union would then develop its own team to handle the disbursement of benefits.

One big problem I see with programs such as this is that much like Federally funded programs (Medicare and Social Security), there needs to be a constant source of funding. The government can continue to raise taxes, reduce reimbursement, and or pressure healthcare entities to reduce costs or close down operations all together. All of which can have a significant impact on the economy. But what happens if foreign automobile manufacturers continue to dominate the market and force the "Big Three" to close. How will these VEBA's stay funded?

I always feel a sense of "entitlement" in programs such as these. Employees that have traditionally made above average wages and salaries (especially in the automobile industry) haven't had to worry about saving money for healthcare coverage and retirement. In retirement pensions are used as income rather than supplemental income and this way of thinking I believe has encouraged the current employees and the younger generation to feel that they should have these benefits as well. Unfortunately, in the "what have you done for me lately? " period of society, I think the employers have to ask the same question. Once a world symbol of dominance in the auto industry, do the "Big Three" even deserve the title anymore? If employers asked "what have you done for me lately?" a little more often I think this sense of entitlement may go by the wayside.

I guess we will have to wait and see.