In Need of a New Hip, but Priced Out of the U.S.
By ELISABETH ROSENTHAL | Published: August 3, 2013
WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.
Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.
Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.
“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”
“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.
“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”
EHealth Wins Approval to Sell Obamacare Health Plans
Online health insurance broker EHealth Inc. (EHTH)won permission from the U.S. government to enroll customers for subsidized plans offered under the federal health-care law. The shares gained the most in almost seven years.
EHealth will be able to tap into a government computer system allowing the company to determine whether people shopping for plans at its website are eligible for tax subsidies for their health insurance, the Mountain View, California company said today in a statement. The information will enable EHealth to offer customers subsidized plans available in their state.
The company has been lobbying the federal government for the agreement, as well as urging similar permission from 14 states that are building their own marketplaces called exchanges to sell insurance to people who don’t get it at work. The exchanges open Oct. 1.
“When there are choices in the marketplace, more presence in the marketplace of various options, it’s likely you’re going to get more enrollment,” EHealth Chief Executive Officer Gary Lauer said in a telephone interview. “At the end of the day, the Affordable Care Act succeeds or fails solely based on enrollment.”
EHealth shares gained 28 percent to $30.74 at the close inNew York, the biggest single-day increase since October 2006.
A patient’s worth, in billing codes
A PATIENT wants solutions; at least, he wants attentiveness. He is preoccupied with the failings of his life.
But I’m preoccupied, too: with counting. If I document one element of his family or social history in the electronic medical record, it’s considered “pertinent,” but two “established elements” — or three “new elements” — are “complete,” and worth more. One-to-five findings on the psychiatric exam are “problem-focused,” but if there are six, the exam becomes “expanded problem focused,” which is also worth more. Reviewing old records is two data points, but reviewing lab tests is only one. Counting, counting.
These numbers add up to a billing code; these billing codes add up to Medicare reimbursement. You combine history complexity plus examination bullets plus medical decision-making plus risk, and out of the confusion an accurate code is supposed to pop clearly into view.
There’s a crib sheet on a corner of the desk: a list of key components of the Current Procedural Terminology codes. It’s a bookie’s scorecard, the Mahjong rules, our little life preserver for land use. It’s covered with numbers, points, and descriptions; the condensation of hundreds of pages of formulas that AMA committees have hammered out over vats of coffee, and probably pints of blood.
Using it feels like spinning the great wheel of chance and seeing what prize money it lands on — except, of course, that this is very precise science. My hands are typing, and I’m adding, subtracting, worrying, re-adding. The patient is still talking, last time I checked.
Out of the confusion, an accurate code is supposed to pop clearly into view.
Auditors will be using these same formulas to check the charts for Medicare fraud. We cannot wish CPT codes away. Most of us have gone to training sessions, downloaded forests of manuals, and followed thousands of arguments on list-serves, in the effort to make them simple. Still, there is confusion, disagreement, and highly educated sweat leaking onto keyboards across the nation, because these formulas are not simple, and, really, not even very useful.
As a result, a sense of fervent, desperate distractedness accompanies listening, now. If I were a patient, I would worry about my worth.
Missouri Citizens Face Obstacles to Coverage
By ROBERT PEAR
JEFFERSON CITY, Mo. — Looking for the new health insurance marketplace, set to open in this state in two months, is like searching for a unicorn.
The marketplace, or exchange, being established by the federal government under President Obama’s health care law has no visible presence here, no local office, no official voice in the state and no board of local advisers. It is being run like a covert operation, with no marketing or detailed information about its products or their prices.
While states like Colorado, Connecticut and California race to offer subsidized insurance to their citizens, Missouri stands out among the states that have put up significant obstacles. It has refused to create an insurance exchange, leaving the job to the federal government. It has forbidden state and local government officials to cooperate with the federal exchange.
It has required insurance counselors to get state licenses before they can help consumers navigate the new insurance market. And, like many states, it has refused to expand Medicaid.
“It’s like running an obstacle course every day of the week, but the course changes from day to day,” said Herb B. Kuhn, president of the Missouri Hospital Association, a strong advocate of expanded coverage.
Colorado Presses for Uninsured to Enroll
By ABBY GOODNOUGH
Published: August 2, 2013
DENVER — Television commercials have already run suggesting that buying health coverage through the state’s new insurance market, Connect for Health Colorado, will feel like winning the World Series.
The market’s employees are traveling the state to explain how it will work, often in electric yellow T-shirts with the message, “Got Insurance?” In the coming weeks, 400 guides will be trained to help the uninsured sign up for coverage, with some targeting groups like Hispanics, gay and lesbian citizens, and even truckers.
This is Colorado, five months before the central provisions of President Obama’s health care law take effect: a hive of preparation, with a homegrown insurance market working closely with state agencies and lawmakers to help ensure the law’s success. Gov. John W. Hickenlooper, a Democrat, is a firm supporter, and the state legislature, controlled by Democrats, has not thrown up any obstacles.
Collins criticizes Obamacare in GOP radio address
6:00 AMThe senator from Maine pushes legislation to define a full-time workweek as 40 hours.
WASHINGTON – Maine Sen. Susan Collins delivered the weekly Republican address on Saturday, continuing her party’s attacks on Obamacare by predicting a provision of the law will prompt many employers to slash workers’ hours.
Collins used the nearly six-minute address to criticize language in President Obama’s health care reform law that defines a full-time workweek as 30 hours. Beginning in 2015, businesses with 50 or more employees will be required to offer health insurance to all full-time employees or face a financial penalty.
The Maine Republican, who voted against the Affordable Care Act, said the result will be some employers reducing their employees’ hours to less than 30 hours a week in order to avoid the insurance requirement. She cited an unnamed school system in Maine that she said is already planning to track the hours worked by substitute teachers to keep them below the 30-hour cap.
America needs cost-effective universal health care
Columns & Analysis |
Sunday, August 4, 2013
In recent months, the people of Maine have witnessed activity by many different players in the health care system as Maine moves to implement the Affordable Care Act.
We’ve seen Gov. Paul LePage veto the expansion of MaineCare, which will leave 70,000 Mainers without access to health care. We’re watching MaineHealth and Anthem try to exclude local hospitals and providers in order to gain “market share” in the upcoming insurance exchange.
We’ve seen highly paid hospital lobbyists and executives successfully persuade Gov. LePage and the Legislature to repay the state’s hospital debt. We’ve learned that businesses are being granted a reprieve from the mandate to offer health insurance to their employees, although individuals remain subject to the mandate beginning in January 2014. Even with ACA subsidies, many of the individual insurance options in the marketplace will be either inadequate or unaffordable for many Mainers.
In the meantime, the problems in the health care system continue to grow. Patients are struggling. The costs of health care consume more than 20 percent of our state’s GDP.
In Maine, an estimated 1,800 individuals and families declared bankruptcy in 2012 due to medical costs. Although some of these people were insured, the majority had health insurance that was inadequate to cover the high costs of medical care. There are 130,000 Mainers who continue to have no health insurance at all; thousands more are under-insured.
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