Sunday 21 September 2014
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Saturday 20 September 2014
Health Reform 2.0: States Balking at New Insurance Exchanges
Health Reform 2.0: States Balking at New Insurance Exchanges
By Karen PallaritoHealthDay Reporter
First part of two-part series
WEDNESDAY, Sept. 19 (HealthDay News) -- Under the Affordable Care Act, the Obama administration's controversial reform of health care, states are supposed to assist uninsured Americans in buying health coverage by setting up so-called "insurance exchanges."
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But, many states are dragging their heels on building the necessary infrastructure -- and some have outright refused to do so.
This lack of action poses a significant challenge to get the law up and running.
Continued Republican opposition to the 2010 law, the U.S. Supreme Court battle to determine its constitutionality, and ongoing uncertainty over the future of health reform after the upcoming presidential election have stymied progress on exchange development, policy experts say.
"The ACA (Affordable Care Act) cannot be implemented without an insurance exchange in each state. It's a go or it's a no-go. It's that simple," said Robert Laszewski, president of Health Policy and Strategy Associates Inc., an Alexandria, Va.-based consulting firm.
So far, only 15 states and the District of Columbia have established exchanges, and three others -- Arkansas, Delaware and Illinois -- have indicated that they will partner with the federal government to do it, according to the Henry J. Kaiser Family Foundation.
Creating insurance exchanges -- which are designed to make it easier for consumers to shop for insurance -- is just one of two big hurdles facing the health reform law. The Supreme Court ruling in June upholding the constitutionality of the Affordable Care Act also allows states to opt out of the law's Medicaid expansion provision -- a key piece in the drive to bring insurance to an estimated 30 million uninsured Americans.
Critics of "Obamacare" hope that state resistance on both fronts will stop the reform effort in its tracks.
State-based health insurance exchanges are a critical part of the planned January 2014 expansion of insurance coverage through the Affordable Care Act, President Barack Obama's signature policy initiative.
Beginning with enrollment in October 2013, individuals and employees of small businesses who are uninsured can go to the exchanges to compare private health plan options across four levels of coverage -- bronze, silver, gold and platinum -- and purchase coverage.
The exchanges must ensure that each health plan offers a sufficient number of providers and meets other minimum standards. To participate in an exchange, an insurer must offer at least one "gold" and one "silver" health plan.
Each state's exchange must also maintain an up-to-date website with comparative health plan information; maintain a toll-free, consumer call center; and fund a "navigator" program to assist individuals and families with obtaining coverage. The exchanges are also the vehicle for people who meet certain income thresholds to qualify for tax credits to reduce their premium costs and federal subsidies to lower out-of-pocket expenses.
The federal government is offering premium assistance in the form of refundable tax credits to people with incomes up to 400 percent of the federal poverty level ($44,680 for an individual and $92,200 for a family of four in 2012) and out-of-pocket spending caps on covered services.
Some GOP governors critical of exchanges
Republican governors in six states have decided not to create a state-based health insurance exchange, and New Hampshire Democratic Gov. John Lynch, in the face of GOP opposition, signed legislation barring the state from creating its own exchange. As many as 16 states are still exploring their options and nine states have shown little progress in planning their next steps, according to the Kaiser Family Foundation's latest tally.
In states that do not create an exchange, the federal government has the authority to do it for them.
States have until Nov. 16 to notify the U.S. Department of Health and Human Services (HHS) of their plans to create an exchange or partner with HHS to help create one. That gives states precious little time after the Nov. 6 election to submit plans and get an exchange up and running by October 2013.
"It looks like 35 states won't be ready, at least," Health Policy and Strategy Associates' Laszewski said.
The federal government insists that it's up to the task of working with states to ensure that the exchanges are in place by the deadline.
"We can guarantee that consumers in every state will have an exchange in place by 2014. There's no question about that," said Fabien Levy, HHS press secretary.
Laszewski isn't so sure. "The administration has been emphatic this last month that they will be ready, but they're not being at all transparent about it. We have no idea how much progress they have or haven't made," he said.
Although HHS issued a final rule on the design and implementation of insurance exchanges in March, many issues remain unresolved, explained Cristine Vogel, associate director in the Chicago health care office of Navigant Consulting Inc., a specialty global consulting firm. The unknowns range from how the government will resolve consumer appeals to how much it will cost states to use the federal exchange, she said.
Detractors, supporters debate exchanges' value
What do states gain by refusing to establish an exchange?
"We look at state refusal as one of the ways that states can protect themselves from the overreach of federal law," said Twila Brase, a registered nurse and president of the St. Paul, Minn.-based Citizens' Council for Health Freedom, which opposes the Affordable Care Act. One way the delay protects states, she said, is by avoiding the high cost of operating an exchange, estimated to run anywhere from $10 million to $100 million a year, depending on the state.
Others see state refusals on health exchange creation as little more than political posturing.
"I think they're taking a political gamble hoping that President Obama is [not reelected], and that is really putting all your money on one number," said Navigant's Vogel. "[They're saying] 'I did not support Obamacare at all.'"
Jon Kingsdale, managing director and co-founder of the Boston office of Wakely Consulting Group and former executive director of the state agency serving as Massachusetts' health insurance exchange, doesn't believe states will shut themselves out of the process of creating an exchange.
"My own sense is that even if the state backs completely away from doing the exchange, there'll still be some coordination" with the federal government, he said.
Even though many people would benefit from the tax credits and consumer assistance that exchanges will offer, exchange implementation, for the most part, isn't even on consumers' radar.
"I really doubt too many people even understand the health-care reform law and the exchanges," Vogel said.
Copyright © 2012 HealthDay. All rights reserved.
SOURCES: Robert Laszewski, president, Health Policy and Strategy Associates, Inc., Alexandria, Va.; Fabien Levy, press secretary, U.S. Department of Health and Human Services, Washington, D.C.; Twila Brase, R.N., president and co-founder, Citizens' Council for Health Freedom, St. Paul, Minn.; Cristine Vogel, associate director, health care practice, Navigant Consulting, Inc., Chicago; Jon Kingsdale, Ph.D., managing director and co-founder, Wakely Consulting Group, Boston, and former executive director, Commonwealth Health Insurance Connector Authority; Henry J. Kaiser Family Foundation, issue brief, August 2012; "Taxation Without Representation: The Illegal IRS Rule to Expand Tax Credits Under the PPACA," Social Science Research Network, July 16, 2012
5 reasons health insurance didn't pay your bill
Kevin Flynn, NerdWallet 7:30 a.m. EDT August 17, 2014
How many times have you gotten a medical bill for more than you were expecting? Chances are, it's happened before, and you're not the only one who's been shocked at the price tag on a service that your insurance should have covered. Here are five possible reasons why your insurance company didn't pay the entire bill.
1. Your insurance company made an error.
Anyone in the industry can tell you that insurance companies are notorious for inconsistent information, and this unfortunately applies to essentially every part of the insurance process. To protect yourself, get in the habit of documenting the date, time and call reference number every time you contact your insurance company. By doing so, if and when something occurs, you have the leverage to dispute your claim because it was ultimately the fault of representatives of the company. For example, if you call to verify that a provider is in your network, and you end up billed for out-of-network services, you'll be able to reference your original call and get your bill reduced.
If you have a question once you get your bill, always call your insurer to ask how the claim was processed and how the amount covered applied to the service. You will receive varied replies, but often, the person at the insurance company will catch a mistake and have it reprocessed.
2. Your provider "accepts your insurance" — but isn't in your plan's network.
Many people think that it is sufficient to verify that your doctor "accepts your insurance," but this doesn't mean you're totally covered. Many physicians will "accept your insurance," in that they will bill your insurance and accept payment, but this doesn't mean that the doctor is in your network. After your appointment, the doctor's office can "balance bill" you, meaning that you will be charged the difference between what was billed and what your insurance paid.
3. Your free annual examination wasn't billed as a free exam.
The Affordable Care Act mandates that annual exams be free — how can this possibly go wrong? Quite easily, it turns out. If you go to your doctor for your free exam but have something else done that isn't considered part of the free exam, the entire exam is billable. For example, if you go in for an annual exam and ask your doctor to look at your ear because you've had an earache, the exam can be billed as an examination with diagnosis, which is no longer free. Before asking for additional services during your free exam, check with your doctor that it won't be billed as an exam with diagnosis.
4. Your insurance company practices "bundling."
"Bundling" occurs when a secondary procedure is considered to be part of a primary procedure. Think of a carpel tunnel procedure: A surgeon will often consider the incision and the carpel tunnel procedure as separate charges. A problem arises, however, when the insurance company considers the incision as part of the carpel tunnel procedure and "bundles" the two charges. In this case, the insurance company will pay only for the carpel tunnel procedure, leaving you to pay for the incision.
Bundling cases are interesting, because sometimes, the doctor is correct, and sometimes, the insurance company is correct. These cases require research into the billing codes used, what occurred during the procedure, and the specialty's (i.e., orthopedics vs. cardiology) standard billing practices. If you have a complicated bundling issue that has lead to massive bills, you might consider hiring a medical billing advocate for professional help getting your bill resolved.
5. There's missing information.
Often, insurance companies will request additional information from the provider, and for whatever reason, the provider does not give the information or it gets lost in processing at the insurance company. If you are not diligent in following up when you receive an insurance statement indicating that nothing was paid, your claim may never be paid. These cases are easily remedied, but you — the patient — must follow up to ensure that the insurance company receives and processes the requested information.
NerdWallet Health is a USA TODAY content partner providing general news, commentary and coverage from around the Web. Its content is produced independently of USA TODAY.
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Friday 19 September 2014
Add Life Insurance to Your Wealth Transfer Toolkit, Saybrus Urges
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September 19, 2014Life insurance can provide efficient, stable income for beneficiaries, insurer says
Advisors looking for ways to manage the explosive wealth transfer that will take place over the next couple of decades — an estimated $30 trillion will pass from boomers to Gen Y, according to consulting firm Accenture — may want to consider life insurance as a way to help clients provide stable income to their heirs.
Palmer Williams, a national sales director at life insurer Saybrus, told ThinkAdvisor that for the right client, life insurance can be an efficient way to pass money from one generation to the next.
"For us it all starts with the client conversation," he said in an interview on Thursday. "When we're part of the conversation and look at wealth transfer or estate planning, that process is built around making sure for the client that the right people get the right things in the right way."
Those conversations may include, in addition to Saybrus and the financial advisor, clients' family members, attorneys and tax professionals, Williams said.
"For a lot of clients — and these are clients generally between the ages of 65 and 80 who are already retired — a big part of that discussion is understanding what their goals are and what their overall financial picture is so we can help the advisor identify what we call 'legacy assets,'" Williams says.
A legacy asset, Williams said, is an asset that isn't needed specifically for retirement. He named four common places advisors can find assets that might not be needed and can be earmarked for an inheritance.
"Generally these assets can be found as annuities that were bought for retirement purposes but once the client is in retirement, they don't need that annuity," Williams said. "IRAs are obviously a big place where we can find legacy money that won't' be used for retirement. General non-qualified investment accounts [are another source] and then Roth IRAs as well."
There are advantages and disadvantages to using those assets both in retirement planning and for wealth transfer purposes, Williams said.
For example, when an annuity is passed to a beneficiary, the gains inside the annuity can be taxed as ordinary income, Williams said.
"An IRA has, just like an annuity, tax-deferred growth throughout earning years and retirement years until you actually pull money out of the IRA, but upon inheritance, that IRA is going to be taxable to the heirs, who in many cases may be in their peak earning years so they may be in a higher tax bracket," he added.
The heir's withdrawal rate is a factor, too, "whether they stretch out the IRA or liquidate it right away."
Non-qualified accounts like a brokerage account are a "great place to have money," Williams said. "Of course, you're paying taxes on a lot of those accounts as you go. Ultimately, when you pass it along there is a step-up in basis."
A Roth IRA, Williams said, is "an excellent place for a client to have money when they pass away. In today's day and age, a Roth IRA is still a relatively new financial instrument, so many clients didn't have the length of time in the work force with a Roth IRA available to build up a large balance, or they may be hesitant to do a Roth conversion with existing assets because of the potential tax hit."
Williams noted that "it's not that one of these vehicles is the answer and they shouldn't have exposure to any [others], but often times life insurance can be an additional piece of the puzzle to help make wealth transfer more efficient."
The No. 1 benefit to using life insurance as a wealth transfer vehicle, he said, is that it can provide predictable income for the beneficiary, even in a market downturn.
"If a client has a $500,000 life insurance death benefit and we come to another 2009 in the market, that 2009 may affect their other assets, but if the life insurance is structured in the right way, that death benefit still remains fixed at $500,000," Williams explained.
Tax benefits associated with life insurance are another stroke in its favor. "As a general rule, life insurance is structured to be 100% income tax free, so that can be very appealing no matter where it's bought, but especially if tax rates change in the future."
A third benefit is that the rate of return compared to premiums paid can be "very competitive," according to Williams. "This will depend upon when the client ultimately passes away, but as an example, at life expectancy a rate of return for the life insurance can be somewhere in the neighborhood of 6% to 8%."
Clients also have complete control over beneficiaries listed for life insurance and it's easy for them to change beneficiaries, if necessary.
Finally, "the death benefit itself is 100% liquid," Williams said. If a client has assets like a vacation home or a business, they may need to be sold to pay the benefit. "Life insurance, because it's 100% liquid, can be an effective way to facilitate that buyout among heirs."
Williams acknowledged that using life insurance for wealth transfer doesn't work for everybody. There are three things that have to be present for it to be appropriate for a certain client.
First, of course, is the client's desire to leave legacy assets to an heir. "The client has to want to leave more, to proactively plan their legacy for their family or a church or charity. Most clients do have that desire as long as it won't affect their retirement lifestyle. There are some clients who don't have that desire, and that's not something we can manufacture."
Obviously if a client doesn't have legacy assets that aren't needed for retirement, they can't pass them on to their heirs, so an advisor has to take a close look at their client's full financial picture. "Many financial advisory firms have different types of software that can help you with your modeling for clients in their retirement years, but you also want to look for some indicators. This works better for clients who already have a stable retirement picture. They may have already been retired for a couple of years. They may have pensions or a long-term care [plan] already in place to help eliminate some of the bigger threats."
"It does involve life insurance so the clients have to be healthy enough to qualify for the life insurance," Williams pointed out. Most insurers will underwrite a client up to age 90, Williams said, but it's better to start when the client is between 65 and 80.
For client couples, only one person has to qualify to be able to use life insurance as a wealth transfer vehicle, Williams said.
"With the stock market at all-time highs," he concluded, "it's a great opportunity to reposition some of the market gains over the last couple of years into a legacy plan."
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Related on ThinkAdvisor:
Relative Value Health Insurance And Pay For Performance For Insurers: Complements, Not Substitutes
Background
The quest for value dominates contemporary health policy. Value, properly defined, is not about cost-savings but about the balance of costs and health benefits — improving the average cost-effectiveness of health interventions. In choosing which care is funded, insurers are a crucial but commonly neglected driver of health system value.
Insurers can increase health system value by covering fewer cost-ineffective interventions or covering more cost-effective interventions. Perhaps the earliest attempt to reform insurance, managed care, attempted to pursue both goals, but by the time it was implemented it widely focused (or was perceived to focus) on cost-containment.
A recent insurance reform proposal, known as Relative Value Health Insurance (RVHI), received considerable attention, for instance, in The Upshot, The Incidental Economist, and Forbes. RVHI enables insurers to reduce their contractual obligation to cover "usual and customary" care. This and similar earlier proposals rely on the insurers' natural incentive to cut costs. Less well-covered, however, are proposals to alter the very incentives of insurers to improve health, which we will call "pay-for-performance-for-insurers" (P4P4I).
Like RVHI and its relatives, P4P4I proposals allow insurers to deny coverage for expensive care that provides few health benefits, but they also incentivize insurers to cover care that they suspect will improve health cheaply. P4P4I faces substantial drawbacks, however, which limit its ability to substitute for traditional health insurance or its RVHI-reformed variants.
In this post, we will categorize existing insurance-based proposals according to whether they reduce contractual obligations to cover care (contract reform proposals) or increase insurer incentives to improve health (P4P4I). We will examine the limitations and advantages of each. Finally, we will offer a proposal for combining the two into a more efficient insurance product.
Overview of Insurance Reform Proposals
Before discussing the relative merits of each proposal, we first describe each. This is not meant to be a definitive list, but rather to capture many of the major proposals in common discussion today or which have interesting features related to the health improvement/cost containment tradeoff.
Relative Value Health Insurance proposes that, rather than the government ranking plans based on the anticipated percentage of all costs that they cover–as is the case with the current "metal" rating system in the exchanges–the government should rank plans based on the maximum cost-effectiveness of interventions that they cover. As an attempt to allow insurers to deny coverage for care that is very expensive relative to the amount of additional health improvement provided, it is spiritually similar to what could be called the Pauly Plan ("last year's care at last year's prices") or even the pure form of managed care (consider the number of denials issued by early 1990's HMO's).
All three approaches — MC, RVHI, and Pauly — operationalize these denials somewhat differently, however. Managed care seeks to customize denials on a per-patient basis, but in untethering itself from explicit contractual language about each intervention opens itself to substantial legal disputes. RVHI declares a cost-effectiveness threshold above which no care will be covered. Pauly's proposal primarily serves to limit coverage of new interventions. (Pauly also alluded to the possibility of using cost-effectiveness for existing interventions, but for the purposes of this post that component of his proposal will be lumped in with RVHI.)
By contrast, pay-for-performance schemes aimed at insurers do not attempt to specify in advance what interventions the insurer must cover or must not be obligated to cover. Instead, they look at outcomes, from proximal ones such as what proportion of patients receive screening thought to be related to health, to distal (or longer-term, more indirect) ones such as blood pressure, to true health outcomes such as the number of myocardial infarctions and deaths.
P4P4I has received much less attention than pay-for-performance-for-providers (typically just called "pay-for-performance") or pay-for-performance-for-patients (P4P4P). The major example so far has been the Medicare Advantage Quality Bonus Payments Demonstration program (MA QBP). The QBP program has focused heavily on process measures; its 48 performance measures include only 3 outcome measures (e.g. readmissions) and 8 intermediate outcome measures (e.g. proportion of diabetics whose blood sugar was well-controlled). Pay-for-Health, a proposal by one of the authors, is conceptually similar, but would involve much more substantial payments for broad outcomes such as the mortality rate.
To understand how P4P4I proposals differ from the contract reform proposals, and in what circumstances they produce similar results, we must dig deeper into the economics of health insurance.
A Brief Introduction to Some of the Economics of Health Insurance
A simple but powerful model of insurance is to conceive of it as having just two stages in which decisions must be made, corresponding to the annual purchase/consume cycles of most health insurance. In the first period (often during an open enrollment period), an individual purchases an insurance contract. In the second (the covered period), she either gets sick or she doesn't. Then the cycle begins again with the purchase of the next year's contract. The question we are concerned with when comparing insurance reform proposals is what interventions the insurer covers in the second period.
Game theorists would call this a "two-period, repeated game." In a repeated game in which a customer purchases a bottle of water at his corner store, he is largely protected from fraud (say, the cashier claiming he handed her a $5 bill instead of a $20 when providing change) because the store knows his future business is worth more than the value of this one transaction. In a repeated game in which he buys a used car, however, he might be stuck with paying too high a price or receiving a low-quality automobile. Two factors combine to produce this different result: the amount of this transaction relative to the anticipated number of future transactions is high, and the amount of information he has is low–if the car breaks three years later he might not necessarily blame to the car salesman.
Health insurance suffers from both of these problems. Turnover in the health insurance market is high, meaning each year's contract represents a substantial fraction of the revenue the issuer will receive from each customer. And, because there are thousands of potential diseases one could develop, each of which with its own evidence base on which interventions improve health and in whom, customers are not likely to notice if the insurer doesn't cover less visible but health-improving interventions.
This problem is particularly acute because, as pointed out by Korobkin and others, with health insurance, the insurer may not want the customers who have the most information about the quality of their product (those who have used substantial amounts of care this year) to buy contracts again the next year, because they are more likely to have higher expenses next year. So insurance companies' incentives are to cover care to the extent that they are legally and contractually obligated, avoid any allowable coverage denials that might receive enough publicity to hurt future contract purchases, and otherwise deny care.
The traditional solution to this problem was the "usual and customary" wording of most insurance contracts. Unfortunately, because of the phenomenon of moral hazard, consumers push for the insurer to pay for care in period 2 that they would not be interested in paying in period 1. Thus, in a traditional health insurance arrangement, we should expect that insurers cover every health-improving intervention they are contractually required to cover–no matter how poor its cost-effectiveness.
Since contract wording is the problem when it comes to too much care, contract wording may provide the solution. The contract reform proposals operationalize this in slightly different ways. The pure version of managed care added other contractual language giving HMOs power to deny or burden certain claims. The Pauly Plan leaves past coverage largely intact but deals with spending growth by empowering insurers to limit coverage of new technologies representing incremental improvements. Korobkin's Relative Value Health Insurance goes after existing interventions that are cost-ineffective by essentially changing contract wording to, "Usual and customary care not exceeding a cost-effectiveness of X."
If traditional health insurance covered every possible health-improving intervention, then these proposals would offer a Panglossian solution: the most health possible for a given insurance dollar. However, given the myriad complaints of providers, public health officials, and providers about denial of cost-effective care by even fee-for-service insurers (as well as suggestive anecdotes such as the decades-long non-coverage of expensive but highly cost-effective smoking cessation programs and other examples), that may not be the case. Insurers may be particularly loathe to cover unusual or not customary care, such as behavioral economics interventions or quality improvement initiatives.
Pay-for-performance-for-insurer proposals tackle the problem of under-provision of high-value interventions. Rather than contractually requiring coverage of usual and customary care, then allowing non-coverage of certain types of care which may be low-value, they place the insurer at risk if customer health does not improve, using metrics related to the patient's health outcomes.
For a P4P4I contract, in the first period a consumer (the insured individual, employer, or government agency) purchases a contract that stipulates penalties and rewards to the insurer that vary depending on the health state of each patient or population of patients. In the second period the insured winds up in a given health state and the insurer pays out accordingly. If the incentives are big enough, the insurer should cover care that makes measured disease states less likely, be it through primary prevention or treatment.
The MA QBP program, then, is really two insurance contracts. The first is a traditional health insurance contract, stipulating that the insurer will pay for all usual and customary care. The second is the contract on health metrics, stipulating that the insurer will receive more or fewer dollars when given health outcomes are achieved. There is no reason to think that the first contract could not be reformed according to either the RVHI or Pauly proposals, as will be discussed later.
Advantages and Disadvantages of Each Proposal
There is no clearly superior proposal. Rather, each carries with it various trade-offs and assumptions. The table summarizes these differences (click on table for enlarged view).
Author's note: Korobkin's proposal is ambiguous as to whether unconventional interventions that fall within the cost-effectiveness threshold of a plan would be covered. It seems not implausible that such an arrangement could be written into contracts.
Value
New interventions are often very expensive relative to health benefits (both because fixed development costs have been paid long ago and because the "easy" targets in drug development were the first to be targeted). Therefore, an insurer operating under RVHI and one operating under the Pauly Plan will have substantial overlap in which interventions they will deny coverage for. With either, the cost effectiveness can be fine-tuned for each plan by changing the threshold.
In their purest form, P4P4I contracts take the value proposition one step further: not only do they enable denial of payment for interventions that are expensive relative to the amount of health benefit, but they enable the insurer to decide on a per-patient basis what to cover and what not to, as long as health improves sufficiently. It also allows insurers to substitute freely between "usual and customary" care and unusual and not customary interventions such as health systems interventions, quality improvement interventions, behavioral economics interventions, and public health-style interventions. While many of these are being covered tentatively by a few insurers, because insurers are not contractually obligated to cover them, their future remains uncertain if they are merely very cost-effective rather than cost-saving.
Domains of health covered
In its pure form (not attached to a traditional health insurance contract), P4P4I can address only those health concerns for which there is a metric available. Particularly likely to be neglected are mental health and other health domains which are not only difficult to measure, but for which available measurements are subjective and therefore subject to manipulation when substantial sums are at risk. The Pauly Plan's emphasis on past treatments may bias coverage away from particular domains for which newer treatments predominate (neurological or oncological treatments, for instance), but overall it is much more able to cover the broad sweep of human health than P4P4I proposals. This may be why MA QBP is tied to traditional health insurance rather than a pure, standalone P4P4I contract.
RVHI is an intermediate case. While there is no technical barrier to developing comparative effectiveness measures for all domains of health, the studies are expensive and even at post-ACA levels of funding it would take decades to develop enough of a knowledge base on which to base an insurance plan. Instead, Korobkin proposes to couple RVHI to what is essentially the Pauly Plan — grandfather in interventions covered before some date, and require all new interventions to come with cost-effectiveness numbers. Just as in the interest of feasibility the MA QBP demonstration linked a P4P4I contract to a traditional health insurance plan, to practically cover more than a few narrow domains of health, RVHI may need to be linked to a (modified) traditional health insurance plan.
Data requirements, governmental intervention, and ease of enforcement
The Pauly Plan's strength is its ease of enforcement and low data requirements — all parties, including courts, should be able to agree on the introduction date of a new intervention. RVHI and P4P4I schemes require considerably more data and consequent governmental involvement in contract enforcement. Compared to managed care, they are more easily enforceable (for those interventions for which cost/comparative-effectiveness studies have been conducted or those health outcomes for which metrics are available), but compared to the Pauly Plan they are considerably less so.
Adverse selection and "cherry-picking"
Any proposal that seeks to limit the generosity of care will be subject to adverse selection (sicker customers selecting into more generous plans) when traditional insurance plans are available. Korobkin and Frakt offer several solutions for this, including shorter open enrollment periods and exclusion of low-value care for some period after switching to a more generous plan. Selection problems with P4P4I, by contrast, come from the insurer's selection decisions. Because performance pay is rewarded relative to the expected health outcomes, insurers will profit handsomely if they are able to attract a healthier customer base. Competition among insurers may be utilized to partially mitigate this problem, by making payments relative to how other insurers' patients fared rather than relative to an absolute standard.
Whence the ACO
Accountable Care Organizations encourage care coordination and are at least potentially incentivized based on health metrics, albeit with substantial drawbacks. Given the breadth of different structures allowable under the ACO umbrella, however, they may be the best hope for implementing P4P4I, at least among those ACOs which incorporate an insurance component or are otherwise large enough to build true health outcomes in as metrics. Even in the absence of an insurer-ACO, however, they may be efficient partners for insurers which have adopted contract reform or P4P4I to implement their value-improving interventions.
Combining Complementary Characteristics
No plan, be it contract reform or P4P4I-based, has a clear advantage over the others. Combining several proposals may have substantial benefits. For instance, an insurer might offer a plan which covered care with demonstrated cost-effectiveness below $25,000 per Quality-Adjusted Life Year (RVHI), also covered all "usual and customary" care invented more than a decade prior (Pauly Plan), and in which the insurer refunded 50 precent of premia if all-cause mortality among the insured rose more than two standard deviations above its peers and conversely received an additional 50 percent of premia if all-cause mortality fell by an equivalent amount (P4P4I).
The strengths of each component complement the others weaknesses. Including broad coverage of medical care mitigates concerns over adverse selection and omitted domains of health inherent to high-powered P4P4I schemes. Including usual and customary care deemed acceptable in the past helps to jump-start the feasibility of RVHI given the limited amount of comparative effectiveness research currently available. Including coverage of newer, highly cost-effective interventions (both through RVHI and through P4P4I) makes pushing back the date-based cutoff of the Pauly Plan more palatable.
Palatability–both political and individual–may be the strongest argument for bringing these insurance reform elements together. Since, in Pauly's words, we lack the courage to adopt "cost reducing but slightly quality reducing innovations," coupling a health-improving, cost-increasing redesign of insurance with a health-neutral or slightly health-reducing but substantially cost-reducing redesign may finally make 'rationing' politically viable. At least as importantly, it may finally achieve the long-elusive goal of shifting insurance dollars from expensive, low-benefit care to less expensive, higher-benefit care.
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This entry was posted on Friday, September 19th, 2014 at 11:37 am and is filed under All Categories, Business of Health Care, Comparative Effectiveness, Consumers, Effectiveness, Health Care Costs, Innovation, Insurance, Payment, Policy, Public Opinion, Quality, Spending. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.
Thursday 18 September 2014
Why does backup and data recovery matter?
Backup and data recovery does matter. Many times, it doesn't tend to matter until it is too late. Those who have experienced data loss are some of the first to proclaim its importance and how much they wish that they had realized that before it was too late. There are also those who thought that they had a reliable backup solution in place, only to find that they did not. Pixar is an example of a company who experienced just such a situation when one of their employees accidentally deleted the master copies of their animated characters and they realized that their backups had not been working properly...for quite some time!
In the article, "Internet security, reliable web hosting, and identity theft concerns," the discussion was started on the importance of backup and recovery, as a part of the overall approach to all things security and safety related for the online presence.
Don't do it just once. Have a backup strategy.
This writer (aka me, Deborah Anderson) has extensive experience in the area of backup and recovery. Some day, that story will be shared. One thing that I recommended was to have a 3-prong strategy. In other words, don't limit one's security to only one solution. It seems the author of this article on approach to backups, shares that opinion and lists some ideas for that same approach. In the case of Pixar, that would have saved their bacon, and in fact, indirectly, it did.
Of course, the "Don't do it just once" also applies to performing the backup process once and then not doing it for several years. But, the key is that there are different options to employ, for that overall backup strategy.
Another step by step approach to a backup strategy is provided by codinghorror.com, starting out with a satirical approach that basically says to change the lifestyle if the desire is to live without the need for backups.
So, what is the first step?
It may be that the first step is the most confusing. The question of where to find the solution and what solution is it that needs to be found?
If the site is a Wordpress blog, there are many plugins that are available to help out in a basic blog backup. One such favorite, that is free, is one available from Backup Technology, specifically for Wordpress. It is free, but there are options for paid upgrades which make backups even more convenient. Also, a search for "backup" in the Wordpress plugin directory produces others that may be of interest.
That may cover the web site, but much more is needed to cover everything else that exists, beyond a blog or site. In other words, the computer needs backup and, if the head of the company, that company also needs coverage (i.e. servers). For this, an all-purpose solution is needed.
For Mac computers, a great solution is to use "Time Machine" that comes with the computer. There are also some available solutions for Windows, like downloads (use at one's own risk) available at CNET Download.com.
There is an advantage to choosing a company (versus a download). The advantages include product support and sales support, in most cases. The sales support should be available so that all questions about the software may be asked before making a buying decision. Look for a company that offers a free trial or a free version so that the software can be "touched" and "tried" before committing to a final purchase.
An example of a company that has a free version and has sales support and product support is EaseUS, with the motto of "make your life easy." This company sets the standards on what a backup solution shopper is looking for by providing multiple services and products for multiple platforms (Windows, Mac, iOS, servers, etc.). This company, and others like it, specialize in the backup and recovery process, and have compiled testimonials and reviews (from PC World, Tech Republic, and more) to prove their point. That is the type of benchmark the shopper needs to look for when considering a company to assist them in their backup and recovery solution.
If it is a corporate approach, another company to consider is EMC, specializing in helping to set up real-time continuous backup solutions and disaster recovery planning for corporations. Their technical project managers are ready to help carve out the solution that is right for the mid-to-large company.
It doesn't have to be complicated.
Data protection (which includes backup and recovery) doesn't have to be complicated and it doesn't have to be scary. If downloading software seems to be confusing, or even using built-in software seems inadequate, then looking for a specialist would seem to be the best option. That specialist can help to ease the mind.. and help one to breath easy, knowing their data is protected.
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Deborah Anderson loves Los Angeles and keeping up with the news. During her time as chief technology officer in the financial industry, she ensured that the safety, security, and peace of mind were covered with the wealth management firms and their high net worth clients. You can keep up with her technology and financial tweets @TechAuditCom and keep up with the Los Angeles love @LuvLosAngeles. Connect with with her directly on Google+.
New York Construction Accident Lawyer Adnan Munawar Issues a Statement After Construction is Halted at Brooklyn's Atlantic Yards Complex
NEW YORK, Sept. 17, 2014 /PRNewswire-USNewswire/ -- According to NBC New York, construction has been stopped at the Atlantic Yards in Brooklyn (Construction Halted on Atlantic Yards Complex, August 29, 2014). Apparently the Swedish construction firm Skanska stopped work at the site, which is near the recently constructed Barclays Center, citing design flaws and tens of millions dollars in extra costs.
The company reportedly had a 117 million dollar contract to supply 930 modules for what was to be a 32-story tower, the first of 14 planned prefabricated structures in the recently named Pacific Park development. The developer of the project, Forest City Ratner, told reporters that it is confident that the buildings will be built and alleged that the dispute is strictly about money.
"If there truly are design flaws in this massive construction project, then kudos to Skanska for not ignoring them," said Adnan Munawar, Partner at Munawar & Andrews-Santillo LLP. "Construction sites are among the most dangerous work environments and it is essential that everything go according to a safe, and well-designed plan. It is unsettling to think what some companies might do when faced with having to spend more money in order to do a project safely, but hopefully the parties at play here are doing the right thing."
"The reality is that there are strict regulations for operating construction sites and corners get gut all the time. That may not be what is going on here, but there are countless injuries to construction site workers that could have been avoided if a proper plan had been in place. Construction accidents can also be quite serious because workers are operating industrial machinery and there are heavy, metal objects that can fall, so it is imperative to know what to do for anyone who is injured on a construction site. It is highly recommended that anyone in this position contact a construction accident attorney right away and start protecting their rights immediately. An attorney will know how to work with experts to prove what caused your injury and get you the compensation you need and deserve so you can focus on recovery and your family doesn't have to worry about lost income."
"If your or a loved one has suffered an injury or worse caused by the performance of a job, contact a New York Construction Accident lawyer to receive information about the workers' compensation claim process and get your claims started right away."
About Munawar & Andrews-Santillo, LLP
http://workers-compensation-lawyers-nyc.com/
http://workers-compensation-lawyers-nyc.com/what-to-do-if-injured-at-work/
http://www.mlawfirm.com/construction-accidents/
Munawar & Andrews-Santillo, LLP ("MLawfirm") is a Personal Injury Law Firm in New York City. Our team of highly qualified and skilled attorneys handles and represents clients in a wide range of legal areas including: Car/Auto Accidents, Bike Accidents, Truck Accidents, Construction Accidents, Workers Compensation, Medical Malpractice and No-Fault Collection/Litigation/Arbitration or Accidents. If you need legal help feel free to contact our attorneys. We are available 24 hours a day, 7 days a week, 365 days a year to our clients. Because Insurance companies have their attorneys, adjusters and representatives well trained to defend, delay and frustrate your right to recover full and adequate compensation and damages. One of our greatest strengths is that we are Trial Lawyers. That means we prepare client's case as if it is going to court and we use tireless effort to secure the best possible results for them. At Munawar & Andrews-Santillo LLP, a preeminent New York law firm s, no case is too large or too small. Our attorneys treat all clients with the respect and dignity they deserve. Our law firm and attorneys work hard to deliver the very best results to all of our clients. Do you have a legal issue? Do not hesitate to call for free consultation at (212)-400-4000.
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