2013년 11월 24일 일요일

About 'cost of home health care'|...to stay in their homes and communities...understand the importance of Alaska's National.... HEALTH CARE - Obviously, high medical costs are ...







About 'cost of home health care'|...to stay in their homes and communities...understand the importance of Alaska's National.... HEALTH CARE - Obviously, high medical costs are ...








Many               of               the               most               discussed               and               most               popular               ideas               for               how               to               fix               our               broken               health               care               systems               rely               on               unsound               premises               and               cost               more               than               they               are               worth               while               delivering               less               than               they               are               supposed               to               deliver.

Here               are               some               examples               that               you               probably               hear               about               almost               every               day               that               do               not               work               as               well               as               you               might               think.

Flexible               Spending               Accounts
               The               idea               seems               so               appealing               at               first,               but               Flexible               Spending               Accounts               are               one               of               the               worst               ideas               ever.

Flexible               Spending               Accounts               were               promoted               as               a               way               to               provide               lower               income               consumers               with               a               tax               break               and               a               way               to               save               money               for               unexpected               health               care               expenses.

Flexible               Spending               Accounts               do               appear               to               provide               a               more               progressive               tax               break               but               that               is               somewhat               illusory.
               To               be               able               to               put               money               into               Flexible               Spending               Accounts               workers               have               to               have               an               excess               of               income               over               expenses.

But               most               Americans               live               from               paycheck               to               paycheck               so               they               cannot               afford               to               fund               Flexible               Spending               Accounts.

This               means               that               the               actual               tax               benefit               is               for               the               rich               who               can               afford               to               fund               Flexible               Spending               Accounts.

But               it               is               worse               than               this.
               When               consumers               put               money               into               Flexible               Spending               Accounts,               they               "break               even"               at               best.

In               fact,               it               is               more               than               a               little               like               going               to               a               casino.

Because               Flexible               Spending               Accounts               have               to               be               fully               expended               each               year,               they               do               not               allow               consumers               to               save               over               many               years               which               would               be               a               much               better               approach.
               Consumers               lose               any               money               left               in               their               Flexible               Spending               Accounts               at               year               end               unless               they               incur               expenses               that               meet               or               exceed               their               contributions.

While               this               encourages               people               to               invest               resources               in               health               care               many               of               these               investments               are               frivolous,               which               increases               the               costs               of               health               care               system               wide.
               A               better               approach               would               be               to               allow               consumers               to               keep               accumulating               the               money               in               their               Flexible               Spending               Accounts,               saving               for               really               rainy               days               such               as               the               onset               of               heart               disease,               cancer,               or               serious               injury.

Allowing               consumers               to               use               the               money               in               their               Flexible               Spending               Accounts               for               health               care               costs,               as               a               hedge               against               lost               income,               and               for               other               health               and               non-health               expenses               when               they               are               sick               or               injured               would               be               a               far               better               approach,               encouraging               savings               over               many               years               for               foreseeable               future               needs.
               But,               without               a               doubt,               the               worst               feature               of               Flexible               Spending               Accounts               is               that               consumers               lose               the               unspent               money               in               their               accounts               at               year               end.

The               legislation               that               brought               Flexible               Spending               Accounts               is               most               notable               for               having               established               a               cottage               industry               of               companies               that               keep               the               unspent               funds               at               the               end               of               the               year               -               an               industry               that               exists               for               no               other               reason               than               to               earn               profits               off               an               unnecessary               program.
               A               simpler,               better               approach               would               be               for               consumers               to               be               allowed               to               put               the               same               money               aside               in               a               regular               savings               account               with               the               same               tax               breaks               for               those               funds               if               they               were               used               only               for               health               related               expenses.

Consumers               could               then               use               the               funds               as               needed               but               would               be               allowed               to               accumulate               these               funds               over               their               lifetimes,               increasing               their               ability               to               cover               their               future               health               care               costs               and               restraining               increased               spending               on               frivolous               health               care               services.
               Medicare               Part               D               Prescription               Coverage
               Again,               Part               D               prescription               benefits               seem               like               an               excellent               idea,               increasing               the               ability               of               senior               citizens               to               pay               for               needed               prescription               drugs.

But,               this               program               has               a               serious               design               flaw.
               The               whole               point               of               insurance               is               to               protect               against               future,               unknown               costs.

But               different               formularies,               the               lists               of               drugs               that               are,               and               are               not,               covered               under               these               programs,               mean               that               senior               citizens               are               required               to               choose               Part               D               plans               that               may               not               cover               the               drugs               they               will               need               in               6               months,               a               gaping               hole               in               the               security               these               plans               provide               to               seniors.
               At               best,               senior               citizens               can               choose               their               Part               D               plan               based               on               what               they               know               about               their               current               prescription               drugs               and               guesses               about               what               drugs               they               may               need               in               the               future.

These               decisions               are               difficult               for               senior               citizens               when               they               first               become               eligible               but               nearly               impossible               as               they               age               and               their               health               declines.

Years               after               making               their               first               plan               selection               senior               citizens               will               inevitably               increase               the               numbers               of               drugs               they               are               taking.
               A               far               better               Part               D               program               would               entail               a               single,               mandatory               formulary               that               all               plans               would               have               to               offer.

This               would               provide               a               true               insurance               benefit               and               avoid               a               great               deal               of               waste               and               fraudulent               activity               in               signing               seniors               up               for               Part               D               plans               that               will               not               meet               their               needs.
               Mis-Managed               Care
               We               hear               a               great               deal               about               managed               care               without               distinguishing               between               two               very               different               kinds               of               managed               care.

Good               managed               care               concentrates               on               the               needs               of               the               patient,               allowing               the               patient               to               access               the               best               doctors,               nurses,               facilities               and               treatments               available               anywhere               in               the               world.

In               this               form               of               managed               care,               if               the               patient               lives               in               New               York               and               the               best               surgeon               for               their               condition               is               in               San               Francisco,               the               patient               is               either               flown               to               San               Francisco               or               the               surgeon               comes               to               New               York.
               But               that               is               the               ideal.

The               type               of               managed               care               most               consumers               experience               is               exactly               the               opposite.

Rather               than               having               the               best               doctors,               nurses               and               facilities               and               treatments               available               anywhere               in               the               world,               mis-managed               care               provides               the               worst               doctors,               nurses,               facilities               and               treatments               available               anywhere               in               the               world               whose               incompetence               cannot               be               proven               by               their               patients.

Even               when               health               care               benefit               plans               know               that               some               providers               are               delivering               sub-standard               care,               they               often               fail               to               remove               these               providers               from               their               panels,               compelling               beneficiaries               to               accept               inadequate               services.
               Instead               of               having               health               care               providers               who               are               uniquely               qualified               for               their               conditions,               most               consumers               get               their               health               care               from               providers               who               are               stretching               their               knowledge,               skills,               and               abilities               to               the               breaking               point.

The               worst               forms               of               managed               care               force               patients               to               accept               the               cheapest               services               available,               with               little               recourse               except               further               delays               in               their               ability               to               access               care.
               Mis-managed               care               is               cheaper               care               for               health               finance               organizations               and               health               care               providers,               but               the               costs               are               borne               by               patients               in               the               form               of               poorer               health               outcomes:               Early               death               and               disability,               delayed               and               denied               care,               and               poorer               health               rather               than               better               health.
               Rather               than               stretching               the               knowledge,               skills               and               abilities               of               health               care               providers,               a               better               approach               would               be               to               make               sure               that               no               provider               ever               practices               outside               the               range               of               their               knowledge,               skills               and               abilities               without               the               their               patients'               informed               consent.
               Consumer               Choice               In               Health               Benefit               Plans
               It               seems               like               such               an               obvious               advantage,               but               somewhat               paradoxically               the               more               choices               consumers               have               in               health               benefit               plan               selections,               the               worse               decisions               consumers               seem               to               make.
               The               language               of               benefit               plans               intentionally               misrepresents               the               costs               and               benefits               of               plans,               preying               on               consumer               ignorance               rather               than               knowledge.
               People               who               think               they               are               healthy,               select               cheap               plans,               assuming               they               will               not               need               them.

It               is               only               when               these               people               become               ill               or               injured,               they               realize               that               their               benefit               plans               will               not               cover               the               costs               of               the               kind               of               care               they               want               available               to               them.
               Even               if               consumers               could               understand               the               language               of               their               plans:               the               benefits,               co-payments,               deductibles,               exclusions               and               waiting               periods;               they               would               be               hard               pressed               to               make               good               health               benefit               plan               selections.

Few,               if               any,               consumers               know               what               their               future               needs               and               costs               will               be.

This               is               precisely               the               reason               that               we               buy               insurance               -               the               essential               uncertainty               regarding               our               future               exposure               to               high               medical               costs.
               Rather               than               1,000s               of               different               health               insurers               and               benefit               plans,               a               better               idea               would               be               to               have               a               single               health               insurance               policy,               used               by               all               health               insurers               and               health               benefit               plans.

Such               a               policy,               much               like               Private               Passenger               Automobile               policies               or               Homeowner's               insurance               policies,               would               be               a               better               way               to               go.
               Providers,               consumers,               insurers               and               the               courts               would               know               the               benefits               available               and               claims               handling               would               be               many               times               more               efficient.

Two               patients               showing               up               to               the               same               provider,               with               the               same               symptoms,               would               not               be               treated               differently               based               on               the               constraints               on               care               built               into               their               different               benefit               plans.

Providers               would               save               money               on               filing               claims               and               insurers               would               save               money               on               paying               claims.
               Turning               Health               Care               Providers               Into               Health               Insurers
               Without               a               doubt,               the               very               worst               idea               in               health               care               finance               has               been               forcing               health               care               providers,               such               as               doctors,               hospitals,               nursing               homes               and               home               health               agencies               to               become               their               patient's               insurers.
               Providers               become               their               patient's               insurers               in               a               variety               of               ways.

Sometimes               they               enter               into               formal               contractual               relationships               -               capitation               contracts               -               where               they               are               paid               a               flat               amount               each               month               for               patient               care.

They               get               this               money,               each               month,               regardless               of               whether               patients               seek               care               or               not.

This               means               it               is               to               the               financial               advantage               of               providers               if               patients               stay               away.

But               there               are               many               other               ways               providers               are               forced               to               accept               insurance               risks:               The               Federal               and               State               Prospective               Payment               Systems               for               Medicare               and               Medicaid               and               episode               based               care               programs               that               appear               to               encourage               better               care               because               providers               are               supposedly               held               accountable               for               the               quality               and               success               of               their               care.

All               these               different               mechanisms               put               providers               at               financial               risk.
               The               often               touted               premise               of               such               plans               is               that               providers               are               supposed               to               save               money               in               the               future,               by               investing               the               money               they               are               give               in               preventive               care               for               their               patients.

The               problem               is               that               these               future               savings               may               be               years,               even               decades,               in               the               future.

In               the               mean               time,               providers               often               get               paid               less               than               the               costs               of               providing               current               care.

Any               additional               money               devoted               to               preventive               care               would               have               to               come               out               of               the               small               pot               of               funds               available               to               pay               the               ongoing               costs               of               chronic               and               acute               care               for               their               patients.
               As               insurers,               most               health               care               providers               are               smaller               and               more               inefficient               than               the               entities               transferring               insurance               risks               to               them.

As               a               result,               insurance               risk               assuming               health               care               providers               are               less               likely               to               earn               reasonable,               sustainable               profits;               more               likely               to               incur               excessively               high               losses;               have               far               greater               exposure               to               bankruptcy               and               takeover,               and               must               reduce               patient               benefits               to               counteract               their               exposures               to               lower               profits,               high               losses               and               insolvency               risk.
               A               single,               national               health               insurer,               would               be               the               mathematically               most               efficient               insurer.

Despite               the               ease               with               which               this               can               be               demonstrated,               politicians,               insurance               and               health               care               professionals,               and               policy               analysts               ignore               this               and               suggest               less               efficient               approaches               to               providing               health               insurance               for               the               nation's               population.
               I               have               been               writing               and               presenting               on               these               and               other               very               bad               ideas               for               many               years.

I               call               my               work               "Professional               Caregiver               Insurance               Risk."               Here               are               some               papers               I               have               written               about               it.
               References
               Cox,               T.

(2010).

Legal               and               Ethical               Implications               of               Health               Care               Provider               Insurance               Risk               Assumption.

JONA'S               Healthcare               Law,               Ethics,               and               Regulation,               12(4):               106-116.
               Cox,               T.

(2006).

Professional               caregiver               insurance               risk:               A               brief               primer               for               nurse               executives               and               decision-makers.

Nurse               Leader,               4(2):               48-51.
               Cox,               T.

(2001).

Risk               theory,               reinsurance,               and               capitation.

Issues               in               Interdisciplinary               Care,               3(3):               213-218.






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