Subject: Re: [Dialog] Health Insurers try to evade the 80% rule Mime-Version: 1.0 (Apple Message framework v1081) Content-Type: multipart/alternative; boundary=Apple-Mail-1--1042651644 X-Universally-Unique-Identifier: 2d3b3dd5-f86c-45ba-8e75-9371209958cf From: Jeffrey Gene Kaplan Bcc: Bob Goff In-Reply-To: <4C4A6A91.2020101@verizon.net> Date: Sun, 25 Jul 2010 08:09:02 -0400 Message-Id: <8D47C79D-E0FB-468D-8ADC-549F97D08D90@sprintmail.com> X-Smtp-Server: mail.optonline.net References: <4C4A6A91.2020101@verizon.net> To: HARP Dialog on HMO Issues --Apple-Mail-1--1042651644 Content-Transfer-Encoding: quoted-printable Content-Type: text/plain; charset=windows-1252 Every industry bears the expense of doing good that generates little or = no profit or loss leaders; while not as profitable, that's the cost of = doing business. If I was a plastic surgeon, flush with revenue, I'd = spend some time in some poorer country and give something back. As a = pediatrician, that happens daily in "little" ways and it lets me sleep = at night. That's also a proud part of the Judeo-Christian = tradition[[1]] and it defines reasonable expectations in terms of our = responsibility as a society. A sociological test I read in college = spoke to this in a treatise called, to paraphrase: 'Who is the keeper of = the commons? How does this reconcile with what Bob Goff told me about undue influence = by vested interests (IBM, Siemons, etc.) in an effort to monopolize the = computerized patient record industry by making the cost of = certification* prohibitively expensive?=20 * Certification may be by the Commission for Healthcare Information = Technology (CCHITSM) Medical Records | Health Care Information Technology | Health Care = Overview | Physicians & Surgeons | Computing & Information Technology = Overview | Internal Medicine | Hospitals | Medical Equipment & Supplies = Manufacturing Reminds me of Alexander Graham Bell's greed and purported technical = crime. On Jul 24, 2010, at 12:22 AM, Harvey S. Frey wrote: > With an ex-Wellpoint VP and lobbyist in charge in Washington, I doubt = that State regulators will get much support from Washington in fighting = Wellpoint's lobbyists. >=20 > Harvey > =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=20 > For Insurers, Fight Is Now Over Details >=20 > By REED ABELSON >=20 > Published: July 23, 2010 >=20 > http://www.nytimes.com/2010/07/24/business/24insure.html?ref=3Dus > The legislative battle over the health care overhaul ended months ago, = but it is hard to tell from the intense effort now under way by = insurance companies to retool a critical provision. >=20 > The law requires health insurers to spend at least 80 cents out of = every dollar they collect in premiums on the welfare of patients, a = critical issue for the companies=92 bottom lines. >=20 > But state regulators are only now deciding what precisely that means, = as they draft the rules to enact the law. WellPoint, which operates Blue = Cross plans in more than a dozen states, wants to include the cost of = verifying the credentials of doctors in its networks. Insurance = companies like Aetna argue that ferreting out fraud by identifying = doctors performing unnecessary operations should count the same way as = programs that keep people who have diabetes out of emergency rooms. >=20 > Some insurers even insist that typical business expenses =97 like = sales commissions for insurance agents and taxes paid on investments =97 = should not be considered part of insurance premiums, which would make it = easier for them to meet the 80-cent minimum. >=20 > The calculation of what is called the medical-loss ratio is crucial to = insurance companies, because the law requires them to refund money to = consumers if they spend too much on administrative costs. >=20 > But consumer advocacy groups and others see the insurers=92 proposals = and their lobbying for a more expansive definition of what would be = permitted as an effort to water down the law by including too many = administrative costs under the umbrella of patient care. =93A lot of = what they are hoping to shift over there does not =97 and should not =97 = qualify to improve an individual policyholder=92s quality of care,=94 = said Wendell Potter, a former insurance executive who now is critical of = the industry and represents consumers in the discussions with state = regulators. On Tuesday, Senator John D. Rockefeller IV, Democrat of West = Virginia, sent a letter to regulators expressing his concern that the = insurers could have too much influence on how the regulations were being = drafted. By his reckoning, insurers and their compatriots have submitted = nearly 160 comment letters, totaling more than 600 pages, to the state = regulators. Consumer advocates have submitted just 23, he wrote. >=20 > =93The health insurance lobbyists failed to beat the health care = reform bill in Congress =97 but with billions of dollars at stake, we = cannot and we should not expect them to throw up a white flag and start = looking out for the livelihoods of American families,=94 Senator = Rockefeller said in a statement. =93They=92re working every angle of the = implementation process to shirk their obligations under the new law.=94 >=20 > At stake, according to a report issued Thursday by Health Care for = America Now, a coalition that supports the new law, is hundreds of = millions of dollars when the law goes into effect next year. If the six = largest for-profit insurers had had to meet the new standards last year, = they would have been required to refund $1.9 billion, the coalition = said. >=20 > The insurers contend that the advocates are discounting the value of = an array of programs aimed at helping patients, which should be = considered an aspect of quality improvement as part of the 80-cent = minimum. >=20 > =93This is a desperate attempt to distract attention away from the = fact that these regulations could put at risk important services and = benefits that improve the quality of care for millions of patients,=94 = said Robert Zirkelbach, a spokesman for America=92s Health Insurance = Plans, a trade association in Washington. The association recently = issued an analysis of what it contends should be included in the = definitions. >=20 > The debate has escalated in recent weeks as the National Association = of Insurance Commissioners, which represents the state regulators, is = expected to submit a final draft of its work as soon as next month to = Kathleen Sebelius, the secretary of health and human services, for = certification. The regulators met this week in Washington to try to come = closer to an agreement on the rules. >=20 > While much of the debate seems arcane, the insurers say the wording of = the new regulations could exclude efforts aimed at improving the quality = of medical care for patients. In its letter to regulators, UnitedHealth = Group, for example, says the current language requiring insurers to = count only those quality efforts that can be measured and produce = verifiable results is much too limited. It points to many programs =97 = helping people to lose weight, for example =97 that are important but = may not produce =93desired results.=94 And while some consumer advocates = argue that the efforts to root out fraud should be considered = cost-saving measures, not patient care measures, Aetna defends its push = to include those activities as benefiting patients because they protect = patients from doctors who would give them diluted chemotherapy drugs, = say, or worthless mammograms. >=20 > =93Notwithstanding any benefit from a financial perspective, we are = fundamentally impacting the quality of care for the patient,=94 said Dr. = Lonny Reisman, Aetna=92s chief medical officer. >=20 > The insurers say they also need to be allowed to count the cost of = promising experiments, even if they have not yet been able to produce = hard proof that they help patients. =93If it doesn=92t work, we=92re not = going to be spending premium dollars on programs that aren=92t = effective,=94 said Alissa Fox, an executive at the Blue Cross and Blue = Shield Association, the trade group that represents the nation=92s Blue = Cross and Blue Shield plans. >=20 > Some insurance commissioners seem sympathetic to the insurers=92 = arguments, including on the subject of how to treat broker commissions, = which have historically been part of premiums. The insurers would = exclude them from premium dollars, making it easier to meet the 80-cent = minimum. The new standards =93could potentially disrupt the availability = of private health insurance, and do not take into account the integral = role of health insurance agents,=94 Kevin McCarty, the insurance = commissioner for Florida, said last week in a letter sent to regulators. >=20 > Insurers also warn that the regulations could backfire. In a letter to = state regulators detailing its concerns this month, WellPoint said the = new rules could =93paradoxically result in reduced health care quality = in the system and higher costs.=94 >=20 > Consumer advocates counter that WellPoint wants only to derail the = process. In his response, Timothy S. Jost, a law professor at Washington = and Lee University in Lexington, Va., who also represents the interests = of consumers, complained that the insurer was essentially asking the = regulators =93to tear up and discard=94 the work regulators had done to = draft these rules. >=20 > WellPoint says its concerns are valid, contending that important = functions like discharge planning when a patient leaves the hospital = could be excluded. >=20 > =93We=92re the ones in this business and experts in the business,=94 = said Brad Fluegel, a senior executive at WellPoint. =93We have no = interest in prolonging this process any more than it needs to be = prolonged.=94 >=20 > Some consumer advocates say they hope the regulators will disregard = the heated arguments on both sides. >=20 > =93We do want to make sure health plans are able to experiment with = efforts to improve quality,=94 said Ron Pollack, the executive director = of Families USA, a Washington consumer group. =93There needs to be = careful thought and balance about what should be included.=94 >=20 > --=20 > =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D > Harvey S. Frey MD PhD Esq. > hsfrey@harp.org www.harp.org > ----------------------------- > The best lack all conviction, while the worst > Are full of passionate intensity. > - Yeats > =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D > _______________________________________________ > Dialog mailing list > Dialog@lists.harp.org > http://lists.harp.org/listinfo/dialog Jeffrey Gene ______________________________ ManagingManagedCare.com is a commercial free resource for practitioners, = advocates and patients (Drupal CMS) Health Care Reform on Change.org Reforming Healthcare & Managed Care on MDNG.com The information transmitted in this message is intended only for the = person or entity to which it is addressed or their designees and may = contain confidential and/or privileged material. Any review, = retransmission, dissemination or other use of, or taking any action in = reliance upon, this information by persons or entities other than the = intended recipient is prohibited. If you received this in error, please = contact the sender, destroy any printed copies and delete the material = from any computer. --Apple-Mail-1--1042651644 Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset=windows-1252 Every = industry bears the expense of doing good that generates little or no = profit or loss leaders; while not as profitable, that's the cost of = doing business.  If I was a plastic surgeon, flush with revenue, = I'd spend some time in some poorer country and give something back. =  As a pediatrician, that happens daily in "little" ways and it lets = me sleep at night.  That's also a proud part of the Judeo-Christian = tradition[[1]] and it = defines reasonable expectations in terms of our responsibility as a = society.  A sociological test I read in college spoke to this in a = treatise called, to paraphrase: 'Who is the keeper of the = commons?

How does this reconcile with what Bob Goff = told me about undue influence by vested interests (IBM, Siemons, etc.) = in an effort to monopolize the computerized patient record industry by = making the cost of certification* prohibitively = expensive? 
*  Commission for Healthcare = Information Technology (CCHITSM)
Health Care Information = TechnologyComputing & = Information Technology OverviewMedical Equipment & Supplies = Manufacturing

Reminds me of = Alexander Graham Bell's greed and  purported&= nbsp;technical = crime.


On Jul = 24, 2010, at 12:22 AM, Harvey S. Frey wrote:

With an ex-Wellpoint VP and lobbyist in charge in Washington, I doubt that State regulators will get much support from Washington in fighting Wellpoint's lobbyists.

Harvey
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D= =3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D

For Insurers, Fight Is Now Over Details

By REED ABELSON
Published: July 23, 2010
http://www.nytimes.com/2010/07/24/business/24insure.html?ref=3Dus

The legislative battle over the = health care overhaul ended months ago, but it is hard to tell from the intense effort now under way by insurance companies to retool a critical provision.

The law requires health insurers to spend at least 80 cents out = of every dollar they collect in premiums on the welfare of patients, a critical issue for the companies=92 bottom lines.

But state = regulators are only now deciding what precisely that means, as they draft the rules to enact the law. WellPoint, which operates Blue Cross plans in more than a dozen states, wants to include the cost of verifying the credentials of doctors in its networks. Insurance companies like Aetna argue that ferreting out fraud by identifying doctors performing unnecessary operations should count the same way as programs that keep people who have diabetes out of = emergency rooms.

Some insurers even insist that typical business = expenses =97 like sales commissions for insurance agents and taxes paid on investments =97 should not be considered part of insurance premiums, which would make it easier for them to meet the 80-cent minimum.

The calculation = of what is called the medical-loss ratio is crucial to insurance companies, because the law requires them to refund money to consumers if they spend too much on administrative costs.

But = consumer advocacy groups and others see the insurers=92 proposals and their lobbying for a more expansive definition of what would be permitted as an effort to water down the law by including too many administrative costs under the umbrella of patient care. =93A lot of = what they are hoping to shift over there does not =97 and should not =97 = qualify to improve an individual policyholder=92s quality of care,=94 said = Wendell Potter, a former insurance executive who now is critical of the industry and represents consumers in the discussions with state regulators. On Tuesday, Senator John D. Rockefeller IV, Democrat of West Virginia, sent a letter to regulators expressing his concern that the insurers could have too much influence on how the regulations were being drafted. By his reckoning, insurers and their compatriots have submitted nearly 160 comment letters, totaling more than 600 pages, to the state regulators. Consumer advocates have submitted just 23, he wrote.

=93The health insurance lobbyists = failed to beat the health care reform = bill in Congress =97 but with billions of dollars at stake, we cannot and we should not expect them to throw up a white flag and start looking out for the livelihoods of American families,=94 Senator Rockefeller said in a statement. =93They=92re working every angle of the implementation process to shirk their obligations under the new law.=94

At stake, according to a report issued Thursday by Health Care for America Now, a coalition that supports the new law, is hundreds of millions of dollars when the law goes into effect next year. If the six largest for-profit insurers had had to meet the new standards last year, they would have been required to refund $1.9 billion, the coalition said.

The insurers contend = that the advocates are discounting the value of an array of programs aimed at helping patients, which should be considered an aspect of quality improvement as part of the 80-cent minimum.

=93This is a desperate attempt to distract attention = away from the fact that these regulations could put at risk important services and benefits that improve the quality of care for millions of patients,=94 said Robert Zirkelbach, a spokesman for America=92s Health Insurance Plans, a trade association in Washington. The association recently issued an = analysis of what it contends should be included in the definitions.

The = debate has escalated in recent weeks as the National Association of Insurance Commissioners, which represents the state regulators, is expected to submit a final draft of its work as soon as next month to Kathleen Sebelius, the secretary of health and human services, for certification. The regulators met this week in Washington to try to come closer to an agreement on the rules.

While much of the = debate seems arcane, the insurers say the wording of the new regulations could exclude efforts aimed at improving the quality of medical care for patients. In its letter to regulators, UnitedHealth Group, for example, says the current language requiring insurers to count only those quality efforts that can be measured and produce verifiable results is much too limited. It points to many programs =97 helping people to lose weight, for example =97 that are important but = may not produce =93desired results.=94 And while some consumer advocates = argue that the efforts to root out fraud should be considered cost-saving measures, not patient care measures, Aetna defends its push to include those activities as benefiting patients because they protect patients from doctors who would give them diluted chemotherapy drugs, say, or worthless mammograms. =

=93Notwithstanding any benefit from a financial perspective, we = are fundamentally impacting the quality of care for the patient,=94 said Dr. Lonny Reisman, Aetna=92s chief medical officer.

The insurers say = they also need to be allowed to count the cost of promising experiments, even if they have not yet been able to produce hard proof that they help patients. =93If it doesn=92t work, we=92re not going to be spending premium dollars on programs that aren=92t effective,=94 said Alissa Fox, an executive at the Blue Cross and Blue Shield Association, the trade group that represents the nation=92s Blue Cross and Blue Shield plans.

Some insurance commissioners seem = sympathetic to the insurers=92 arguments, including on the subject of how to treat broker commissions, which have historically been part of premiums. The insurers would exclude them from premium dollars, making it easier to meet the 80-cent minimum. The new standards =93could potentially disrupt the availability of private health insurance, and do not take into account the integral role of health insurance agents,=94 Kevin McCarty, the insurance commissioner for Florida, said last week in a letter sent to regulators.

Insurers also warn that the regulations could = backfire. In a letter to state regulators detailing its concerns this month, WellPoint said the new rules could =93paradoxically result in reduced health care quality in the system and higher costs.=94

Consumer advocates = counter that WellPoint wants only to derail the process. In his response, Timothy S. Jost, a law professor at Washington and Lee University in Lexington, Va., who also represents the interests of consumers, complained that the insurer was essentially asking the regulators =93to tear up and discard=94 the work regulators = had done to draft these rules.

WellPoint says its concerns are valid, = contending that important functions like discharge planning when a patient leaves the hospital could be excluded.

=93We=92re the ones in this business and = experts in the business,=94 said Brad Fluegel, a senior executive at WellPoint. =93We have no interest in prolonging this process any more than it needs to be prolonged.=94 =

Some consumer advocates say they hope the regulators will = disregard the heated arguments on both sides.

=93We do want to make sure = health plans are able to experiment with efforts to improve quality,=94 said Ron Pollack, the executive director of Families USA, a Washington consumer group. =93There needs to be careful thought and balance about what should be included.=94 

--=20
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D
Harvey S. Frey MD PhD Esq.
hsfrey@harp.org  www.harp.org
-----------------------------
The best lack all conviction, while the worst
Are full of passionate intensity.
- Yeats
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D
_______________________________________________
Dialog mailing = list
Dialog@lists.harp.org
http://= lists.harp.org/listinfo/dialog

Jeffrey Gene

ManagingManagedCare.com is = a commercial free resource for practitioners, advocates and = patients (Drupal CMS)

Health = Care Reform on Change.org

Reforming Healthcare & Managed = Care on MDNG.com

 The information transmitted = in this message is intended only for the person or entity to which it is = addressed or their designees and may contain confidential and/or = privileged material. Any review, retransmission, dissemination or other = use of, or taking any action in reliance upon, this information by = persons or entities other than the intended recipient is prohibited. If = you received this in error, please contact the sender, destroy any = printed copies and delete the material from any = computer.

<= /div>

= --Apple-Mail-1--1042651644--