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Get health insurance via employer? ACA repeal will affect you, too

Posted by on January 14, 2017


Summary: “Much of the recent attention on the future of the Affordable Care Act (ACA) has focused on the fate of the 22.5 million people likely to lose insurance through a repeal of Medicaid expansion and the loss of protections and subsidies in the individual insurance market,” JoAnn Volk writes over at Health Affairs (Related graphic: Andy Slavitt posts on his Twitter stream about the effects of repeal; click image to enlarge.) “Overlooked in the declarations of who stands to lose under plans to “repeal and replace” the ACA are those enrolled in employer-sponsored health plans — the primary source of coverage for people under 65. Job-based plans offered to employees and their families cover 150 million people in the United States. If the ACA is repealed, they stand to lose critical consumer protections that many have come to expect of their employer plan. It’s easy to understand the focus on the individuals who gained access to coverage thanks to the health reform law. ACA drafters targeted most of the law’s insurance reforms at the individual and small-group markets, where consumers and employers had the greatest difficulty finding affordable, adequate coverage prior to health reform. The ACA’s market reforms made coverage available to those individuals with pre-existing conditions who couldn’t obtain coverage in the pre-ACA world, and more affordable for those low- and moderate-income families who couldn’t afford coverage on their own. Less noticed, but no less important, the ACA also brought critical new protections to people in large employer plans. Although most large employer plans were relatively comprehensive and affordable before the ACA, some plans offered only skimpy coverage or had other barriers to accessing care, leaving individuals—particularly those with costly, chronic health conditions—with big bills and uncovered medical care. For that reason, the ACA extended several meaningful protections to employees of large businesses.” JoAnn Volk, “Get Health Insurance Through Your Employer? ACA Repeal Will Affect You, Too,” Health Affairs.


Escalator clauses, rising prices, and why we should care

Posted by on January 7, 2017
By Jnzl's Photos, released on Flickr under the Creative Commons Attribution License

By Jnzl’s Photos, released on Flickr under the Creative Commons Attribution License

Summary: You may have asked yourself why health prices rise inexorably. Are escalator clauses, the automatic price increases common to many managed care contracts, the driving force behind trend factors? Bill Rusteberg, an independent insurance consultant in Texas, posted on his blog recently about escalator clauses, which he said commonly add 5 percent a year to a provider’s annual billing. I was interested, and called him to chat about it. Bill, who’s been in the health care industry for 44 years, advises and assists plan sponsors or companies in managing their health insurance, on a fee basis. He’s based near Victoria, Texas, in the south central part of the state. Here’s the text of our interview, lightly edited for clarity.

Jeanne Pinder: You posted on your blog about escalator clauses and whether they’re the driving force behind trend factors. What is an escalator clause?

Bill Rusteberg: It’s a pay raise guaranteed by the managed care contract, where providers are guaranteed an automatic increase in pay every single anniversary of the managed care contract. So if there’s a 5 percent escalator clause, that’s really a 5 percent raise every year.


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PriceCheck: Across the nation, community-built health cost guides

Posted by on December 23, 2016

Summary: Our work with PriceCheck, our health cost transparency partnerships with media and other organizations, has stretched across the nation, bringing thousands of people to our partner web sites to share and search prices — from databases, from our reporting, and from our communities. Our interactive software is placed on our partners’ sites, using pricing information from three sources. First, we pre-populate the database with our survey of cash or self-pay pricing collected from local providers on common, shoppable procedures — or, sometimes, prices of bigger-ticket items. Second, we encourage community members to come and share their pricing information, from their bills or “explanation of benefits” forms from an insurer. Third, in most partnerships, we also display the Medicare reimbursement rate for a collection of 8,400 procedures catalogued in the Healthcare Common Procedural Coding System (HCPCS) used by the government in any different geographic regions. In this way, we display a 360-degree view of pricing. We don’t have every price for every procedure at every provider across the nation — that data does not exist anywhere — but we have a “community-created guide to health costs” that informs people and gives them a sense of agency in the bewildering world of health care pricing.  People can share and search the data, and we use the data to write and tell about the costs of health care.

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At the wrong hospital, you’re 3 times more likely to die: New York Times

Posted by on December 17, 2016

Summary: “Not all hospitals are created equal, and the differences in quality can be a matter of life or death,” Reed Abelson writes over at The New York Times. “In the first comprehensive study comparing how well individual hospitals treated a variety of medical conditions, researchers found that patients at the worst American hospitals were three times more likely to die and 13 times more likely to have medical complications than if they visited one of the best hospitals. The study, published Wednesday in the academic journal PLOS One, shows  ‘there is considerable variation in outcomes that really matter to patients, from hospital to hospital, as well as region to region,’ said Dr. Thomas H. Lee, a longtime health care executive who was not involved in the research. The study’s authors looked at 22 million hospital admissions, including information from both the federal Medicare program and private insurance companies, and analyzed them using two dozen measures of medical outcomes. Adjusting the results for how sick the patients were and other factors, like age and income, the researchers discovered widespread differences among hospitals. Even a hospital that had excellent outcomes for heart care might have poor outcomes in treating diabetes. The study did not disclose which hospitals had which results. Under the terms of the agreement to receive the data, the researchers agreed to keep the identities of the hospitals confidential.” Reed Abelson, “Go to the Wrong Hospital and You’re 3 Times More Likely to Die,” The New York Times.


Millions have pre-existing conditions that would make them uninsurable: Kaiser Foundation

Posted by on December 17, 2016

Summary: “A new Kaiser Family Foundation analysis finds that 52 million adults under 65 – or 27 percent of that population — have pre-existing health conditions that would likely make them uninsurable if they applied for health coverage under medical underwriting practices that existed in most states before insurance regulation changes made by the Affordable Care Act. In eleven states, at least three in ten non-elderly adults would have a declinable condition, according to the analysis: West Virginia (36%), Mississippi (34%), Kentucky (33%), Alabama (33%), Arkansas (32%), Tennessee (32%), Oklahoma (31%), Louisiana (30%), Missouri (30%), Indiana (30%) and Kansas (30%). States with the most people estimated to have the conditions include: California (5,865,000), Texas (4,536,000), and Florida (3,116,000). Using data from two large government surveys, the analysis estimates the total number of nonelderly adults in each state with a health condition that could lead to a denial of coverage in the individual insurance market, based on pre-ACA field underwriting guides for brokers and agents. The results are conservative because the data don’t include some declinable conditions. The estimates also don’t include the number of people with other health conditions that wouldn’t necessarily cause a denial, but could lead to higher insurance costs based on underwriting.” Source: An Estimated 52 Million Adults Have Pre-Existing Conditions That Would Make Them Uninsurable Pre-Obamacare,” The Henry J. Kaiser Family Foundation.


Escalator clauses examined as an underlying factor: Risk Managers

Posted by on December 14, 2016

Summary: “Are escalator clauses, common to most Managed Care Contracts, the driving force behind trend factors?” Bill Rusteberg writes over at, his blog. Bill’s a broker in Texas, and a man with an encyclopedic knowledge of health care. “An actuary’s primer I stumbled upon while reading incredibly boring stuff (my answer to sleeping pills) may provide a clue: ‘Medical cost trends include components for many drivers.  Net unit price increases from providers drives half of the effect in general.  So a 5% increase in a schedule will drive a 10% overall cost increase.  The rest of the components include: increased utilization, coding creep, deductible leveraging, etc…’ This is wildly interesting! Escalator clauses average 5% and more (‘more’ being more common), compounded year after frigging year! (Excuse me but I do get emotional sometimes and it’s not a women thing!) That equals 10% compounded year after year after year.” Bill Rusteberg, “Managed Care Contracts & Trend Factors,”


The share of health costs paid out of pocket worldwide: The Data Blog

Posted by on December 10, 2016

Screen Shot 2016-12-10 at 12.00.27 PMSummary: “In many low and middle income countries, out-of-pocket healthcare expenditures are high, and can be a significant financial risk to the poor. Universal health coverage (UHC) is about people having access to needed health care without suffering undue financial hardship,” a blog post on the World Bank’s Data Blog says. This map screenshot is not interactive, but the one on the site is. “Out of pocket expenditure is any direct outlay by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups. It is a part of private health expenditure.”Chart: What Share of Health Costs are Paid Out of Pocket?” The Data Blog.


10 steps for appealing a claim or bill: Part 2 of our series on billing

Posted by on December 4, 2016
 © 2009 Steven Depolo, Flickr | CC-BY | via Wylio

© 2009 Steven Depolo, Flickr | CC-BY | via Wylio

Summary: So you got a huge bill, and you’re sure there’s been a mistake, either in the bill or the insurer’s processing of a claim. You want to appeal, because it’s a lot of money. Here’s a step-by-step course of action. We cannot guarantee that you will win, but at least you will have tried. Read first, and then dive in! And if you want us to help, let us know. Sometimes we can, though arguing bills is not our core business — we love to tell people how to avoid bad bills on the front end if they can. This is Part 2 of a series: You may also be interested in Part 1, “How to find out what stuff costs in advance.”

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Blondie and the (Medical Billing Error) Beast, Part 3: APPEAL WON!

Posted by on November 19, 2016

Summary: “More than a month after my last update detailing Blondie’s labrum tear surgery final claims appeal filing, I received this note from her mother,” writes Mandi Bishop over at, in the third and final part of a series on challenging medical bill denials. 
“Dear Mandi and Mike,
I just wanted to let you know that D just finished a meeting with the (employer) person who deals with health insurance issues ( I don’t know the proper title.) Anyway, she said that they just got confirmation that Insurer X has recently finished reviewing our appeal and has deemed that the medical payments will start being paid to the providers! She also said that the appeal you 2 put together on our behalf included all the information that Insurer X SHOULD have received in the first place, and that the Provider X office did not include said info originally like they should have. She also told D that if we have ‘overpaid’ on our part ($$$ that should have been paid by Insurer X) then they will credit those amounts back to our payment card and it will ‘roll-over’ into 2017 for our medical needs in the next year.
I am ecstatic beyond words, and cannot wait until D gets home tonight so we can celebrate. And maybe now he can start sleeping properly too, with this huge burden off his mind.” 


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A.C.A. repeal without replacement could spur insurer exodus

Posted by on November 18, 2016

Summary: “The incoming Donald Trump administration and Republicans in Congress reportedly are rushing to repeal most of the Affordable Care Act within days of taking office, with a possible delay of a year or two while they craft a replacement package,” Harris Meyer writes over at Modern Healthcare. “They’re also discussing quick administrative moves to unravel the ACA, such as terminating payments to insurers that compensate them for reducing cost-sharing requirements for lower-income exchange plan members. But pro-ACA experts and some insurers warn that repealing the law without passing a replacement, combined with administrative actions undermining the law, could prompt health plans to abandon the individual insurance markets in 2018. That’s because insurers have to calculate and submit their 2018 premiums by spring, and that task will be difficult or impossible if they don’t know the rules of the new Republican-led system. The turmoil likely would affect both the exchange and off-exchange markets, through which nearly 20 million Americans get coverage, they say. ‘I would not be surprised by a stampede to exit the market for fear of uncertainty and the strong potential for adverse selection,’ said Mike Kreidler, Washington state’s insurance commissioner, at a news conference Wednesday organized by the liberal Center for American Progress. Kreidler said he’s already gotten calls from nervous insurance leaders and plans to meet soon with the CEOs of the three major insurers in his state, where half a million people have gotten coverage under the ACA.” Harris Meyer, “A.C.A. repeal without replacement could spur insurance exodus,” Modern Healthcare.

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