The truth can help us come closer to understanding the value of our work for a customer. Lies never benefit a customer and so we often tell truthful stories to help us shed light on areas of improvement.
“This caught my eye over the weekend. Does this change our decision matrix at all?”
This customer is in the middle of making decisions today for their employees. I wrote the email that follows to help them understand what this article is really about. The customer can move ahead as planned but should know more changes are coming for Obamacare. More importantly I explain how this article is an example of how the government and insurers do not care about your health.
If that’s important to you read on.
The article includes this CEO quote,
“We cannot sustain these losses,” Chief Executive Officer Stephen Hemsley told analysts on a conference call. “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself.”
My email to my business customer asking about how this UHC article may affect their present decisions for their employees.
Short answer to your question about UHC:
No, what they’re deciding makes no difference for your decision today. Your decision today will only be good until they make more changes and they do that everyday. What you decide today could change tomorrow, that’s not a joke, that’s real.
Long answer to your question about UHC:
Still, the answer is no, this won’t affect you in the short term and you can’t plan long term.
I’ve been using the words, “shifting sands” for 5 years now. The Obamacare law is 5 years old, March 23rd, 2010. Shifting sands means continuous course corrections by all system stake holders that affects more than $2-3 Trillion of the American economy. This means, today UHC is saying they’re out. But, what it actually means is they’re lobbying for more money. What we have going on here is “lobbying for position.” In the halls of congress, the industry exerts leverage in order to get more money from the government. Welcome to modern politics.
Sad, but true, I can confidently say, I’ve never seen a bigger mess. Before Obamacare, Healthcare needed a fix because the insurance industry wouldn’t police itself. But, this isn’t a fix and national healthcare won’t fix it any better either (watch my video on, “US healthcare system in crisis”).
My guess about UHC? UHC and the feds will make up; the feds will give UHC more money (this will drag on over the next few months) and in order to give them money they have to make the fix look like they didn’t. In the end, just more rules, overhead, confusion and frustration; and cost.
Summary: The government is making massive changes everyday while the plane is flying. Thoughtless unread regulations created this mess and their fix is a daily stream of thousands of new patches, regulations, paperwork and confusion. I’ve been living in the trenches for 5 years trying to help employers understand and navigate. The reality and size of this law is starting to impact small employers like you.
There has been NO improvement in health or cost because your health doesn’t matter to them (any of them). What are we going to get if we keep doing what we’ve been doing? Do you expect a different result?
“Insurers say Obamacare changes needed soon to protect companies from losses” USA Today, 11-24-2015.
“New research out this week from Commonwealth Fund shows far fewer people think their insurance premiums and deductibles — from employer-provided or exchange plans — are affordable than the government does when it defines affordability. About 40% of 2,700 people surveyed said they delay care and prescription refills when they were sick because of high deductibles, Commonwealth found.”
All human life matters and to my way of thinking it’s good the autos and government have a way to track responsibility. I live in Detroit so that makes me a car guy. I feel attached to the auto industry. It’s good the cars we drive are safe.
Outrage over car deaths, of course, makes sense. And, the autos have taken responsibility because the government has a good method to enforce the autos to be accountable to the public.
General Motors will pay $900 million to settle criminal charges related to its flawed ignition switch that has been tied to at least 124 deaths.
CNNMoney (New York) September 17, 2015: 2:46 PM ET; “GM CEO: ‘People died in our cars’ ” Poppy Harlow
When I talk about our medical system is broken, it’s clear that if the auto tracking method were applied to hospitals we’d have accountability.
Here’s a quote from the same article;
In the hearing’s closing questions, when Sanders inquired as to why this crisis was not constantly splashed across front page news, he was met with this: “When people go to the hospital, they are sick. It is very easy to confuse the fact that somebody might have died because of a fatal consequence of their disease, versus they died from a complication from a medical error,” Jha said. “It has taken a lot to prove to all of us that many of these deaths are not a natural consequence of the underlying disease. They are purely failures of the system.”
In our premiums and in our government run healthcare we pay for these services.
But, our system requires more fixes than just this. The white paper is breaking apart many pieces of the medical system apparatus in order to demonstrate the areas where the system is broken. Follow the white paper for what’s wrong, then we’ll be publishing the fixes in 1qtr 2016.
So, I’m innocently reading the news and find myself researching a reporters comment.
Okay, so I’m conflicted. Either the reporter misquoted, misunderstood or is intentionally quoting incorrectly.
This is an unusually long post, but it has a number of good points. I didn’t wake up today planning on writing this post. But, it’s a good chance to write about things I’m passionate about that most people don’t spend their day thinking about.
healthcare rules and how Universities shape our physicians
how rules and word smithing is important
how abortion is learned
how insurance companies rely upon this training
how us as Americans pay for this
that rationing exists in our system today, this is an example
the inconsistency in thinking that is soooooo costly
For those doctors and healthcare professionals who follow me, please engage with me on this note.
The reporter writes about, “The decades-old relationship between MU and Planned Parenthood,” says of medical school education;
Nursing and medical students were never required to work at any Planned Parenthood clinic, work at the clinic was not part of the core curriculum in either the nursing or medical schools and the placement was an optional…
Columbia Missourian, Elise Schmelzer, Sep 15, 2015; “State investigation focuses on decades-old relationship between MU, Planned Parenthood”
But, in doing a small amount of digging, I found the association responsible for setting out the rules for residence in training for OB work are required to train on abortions. My brain is a word smith brain which means I can’t reconcile what the journalist wrote with what I found in a quick look at her own link on the topic. I didn’t perform any further analysis but I’m sure the topic has much more detail.
When I read a journalists article that might be misleading I have to look for the detail. I want to know why does this not sound correct to me. I have an advantage over a young journalist with 29 years in healthcare finance. In this case, I wondered if the reporter intentionally left out an important fact, or skewed a statement. You decide. I think if they asked a few more questions they may have blown open a different discussion. And, an important one at that. They may have discovered the school is training residence on abortion, just not at planned parenthood. Makes you wonder if they use the tissue like planned parenthood, but they use it for University research. It is universities that use the tissue. The article and title make it sound like the university isn’t using planned parenthood clinic and are innocent of any relationship with the abortion business. Innocent enough I suppose on the surface, but what is the rule for OB’s? Where do the residence at this University get their required training?
A very small misquote, or misstatement changes the flavor of the article completely, upon close inspection, the phrase, “at a student’s request” conflicts with the written rule for the Universities accreditation. Here is the authors quote, it’s there in bold.
The agreement with the medical school was required to meet Accreditation Council for Graduate Medical Education requirements that mandated schools provide training on abortion procedures at a student’s request, MU Chancellor R. Bowen Loftin said in a letter to Schaefer.
Columbia Missourian, Elise Schmelzer, Sep 15, 2015; “State investigation focuses on decades-old relationship between MU, Planned Parenthood”
It might seem silly but I live in a world of insurance where rules guide how our medical system works including how much it costs. Think about it this way, our educational institutions work because they have many rules to guide education. They are the one’s who write the rules, and these rules are used to train your favorite doctor. These rules make it possible for insurance companies to pay claims.
So, here’s my word smith problem. The quote below is a rule from a body that gives accreditation to medical education programs and this quote says it is mandatory for University programs, to be accredited, they must provide abortion training. It does not say, what the journalist wrote, “at a student’s request.” The rule as quoted says, they must train residence in abortion.
See, it says it right below in bold.
It’s on page 15 of the ACGME instructions, rules and guide (the journalist provided this link in their article). These rules are used by insurance companies to make sure doctors are properly accredited by properly accredited university training delivering the best care to the insurance company patience. These things, these rules, matter.
“IV.A.6.d) Family Planning and Contraception IV.A.6.d).(1) Programs must provide training or access to training in the provision of abortions, and this must be part of the planned curriculum. (Core) IV.A.6.d).(2) Residents who have a religious or moral objection may opt-out, and must not be required to participate in training in or performing induced abortions. (Core) IV.A.6.d).(3) Residents must have experience in managing complications of abortions and training in all forms of contraception, including reversible methods and sterilization.”
ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology, ACGME approved major revision: September 28, 2014; effective: July 1, 2015, Page 15.
This quote is current, the document doesn’t dictate any specific place for the training, it doesn’t even mention planned parenthood.
Rationing is a phrase I use and when I do most people do one of two things; their eyes glaze over in confusion, or they object out of ignorance because they incorrectly believe rationing will never happen in America. In fact, this article, this misquote or misstatement by the person quoted leads to rationing.
Let me try a different tact.
You’ve been to school and you know from the office of the registrar to commencement day policies, paperwork and rules are required before you get your diploma. It shouldn’t surprise anyone then, that there’s rules for medical school.
Ever wonder where the rules come from? Who writes them, why they write them a certain way? Ever wonder why these rules are important? Did you ever consider these rules influence the healthcare you pay for? Do you understand how this simple language has an evil twist for medical students? Ironically, what the author wrote would be the logical way most people would write the rule, “students have the choice if they want the training.” But, the fact is, the training is required and students at that University are getting it. I haven’t researched this, maybe, the University is outside the norm and their doing it as quoted. Then, the national standards for OB’s is not being followed and this is not a good thing….
It leaves me in this article examining the person in the article who the journalist quoted as not telling the truth, or answering the journalists question about planned parenthood with a strictly narrow answer. And, the unknowing journalist innocently took them at their word. Or, the journalist intentionally wrote an untruth.
The point? The point is OB residence are mandated to take abortion training, it’s not optional. They can opt out for religous beliefs. This is opposite what the journalist wrote. She wrote, students can opt in for that training. This would be how most Americans would assume it’s taught, as an option for medical students. It is a small, razor thin edge isn’t it.
Okay, shift for a minute with me to the actual topic of abortion
Consider that our country makes physicians learn how to perform induced abortions and kill babies. They are in fact babies because this same system pays million upon millions to keep alive babies at the exact age. The contrast to me, originally a claim payor is almost too much to bare. Why, how, as a country did our healthcare system get to a point where this contrast is so great.
It’s because the masses follow what they read from journalists, because they’re not word smiths, because they don’t have time, blah, blah, blah.
This is where the problem starts, it’s where the evil begins. It’s where medical students, in the hallowed halls of educational institutions are provided the means to promote abortion, to agree with them as a course of study and health for a women. You have promoted this behavior by paying for the medical school education, by paying insurers premium, by having policies that promote the idea this is healthcare, that new physicians are mandated to learn about and accept abortion as care. The societal endorsement for doing abortions is trained, it is a medical school endorsed practice.
For the baby, for the voice of the babies, for increased medical premiums, for rules that don’t provide health but death we need to change our methods in the US.
If you’ve slugged through my poor grammar today I hope the overall point was worth it. I’ll return to edit grammar and such but for now, this should suffice.
Moving away from systems of record to systems of Engagement
Watch for less than 2 minutes. I’ve marked it to start at about the 30 second mark, if you watch 2:00 minutes mark you’ll capture what I’ve quoted below.
Geoffrey Moore, author of Crossing the Chasm, writes and talks in an understandable way. He is clear about the challenges facing institutions and legacy systems. Slow to happen for a reason, says Mr. Moore:
“unfortunately, it’s not happening nearly as fast as anyone wants because there’s a lot of complications with bringing consumer technologies into the enterprise…”
“… it’s not as actionable yet as we want it to be, we’re so good at doing the system of record actions because we’ve been doing them for decades. This is newer, there’s legal issues such as privacy issues, there’s lots of technical issues as well and so I think people feel a little bit like, my God, there’s such a big hill to climb, where do we start…”
Automation of the Decoder is next for this reason:
I see the automation looking like what Mr Moore calls, “moment of engagement.”
“moments of engagement, which are the critical strategic moments where your strategy wins or loses, and see if you can’t get the technology involved there because that would really change the performance of your company.”
Today insurance and in particular healthcare processes are rooted in “systems of record.” These are legacy systems and processes still require a fax machine to communicate. It’s human intervention in many places. There is a lot of work to do and it won’t be easy but the rewards will be significant. This video clip underlines the fact that moving out of systems of record and into systems of engagement will be hard work and difficult because of the complexities.
I’m hopeful that others who want to enter this space can find their way, marrying underwriting, technical, compliance and operational histories with the latest technology are whats needed.
Small Businesses are putting their businesses at serious risk
In talking with prospective employers one of the most popular topics that arise is self-funding. It being sold like it is the magic solution for employers. The fact is, it’s being sold because it’s an expedient way for carriers and group agents to “stay in the group market.” This means, by offering self funding as the preferred option to “save money” the agent can keep an employer in a “group” policy.
A group policy is much better for a group agent because they can maintain the employer relationship and write greater premium with one policy, the commission is greater too. It is much easier to sell the “popular” fad solution than to dig into the specific details of your plan. There is a large investment of time needed to do the best job comparing all the possible options.
Unfortunately, in the process to “win the sale” important facts about self-funding are left out. There are pitfalls to self funding no matter what your agent, consultant, carrier, TPA or administrator may say. Employers must consider the small print about self-funding before jumping in.
For larger employers, there are benefits to self-funding, but for a group of 25, 40 or 75 employees it is a bad idea. The proposed gain can easily be outweighed by an unexpected $1,000,000 unpaid claim.
Here’s a short list of reasons that should give a small business owner pause before self funding.
1 – Being an Insurance Company Isn’t On Your Bucket List
Being self funded means you move out from under the safety of having an insurance company paying claims. There’s the potential that you may have to pay claims when the TPA/administrator/insurer decides not to pay.
Not to mention, all the new rules and obligations.
2 – You Want to Buy Coverage, Not Be the Coverage
Here is a quote that most people would call the “small print.” You won’t find it in the typical sales material or presentation. You will find it when you’re asked to defend the non-payment in court.
“The participating employer agrees to be solely responsible for compliance with all laws, including the payment of any required benefits that are not covered as illustrated in the Summary Plan Description or the stop loss policy.”
Administrator Actual Policy Language
3 – You Become The Expert In Making This Decision
This carrier is being honest when they say, you should have experts telling you what to expect before you choose self-funding. This quote is a warning found in the sales material.
“While many employers can benefit from a self-funded plan, it may not be the right choice for every business. The biggest question a small group employer has to consider is if the additional risk will jeopardize their business.”
Administrator Advertising Materials
If you self-fund you will need a qualified person to evaluate your risk before making the decision. Your sales agent, consultant, insurer, CFO, HR person are not qualified to make this assessment. Will they pay the claim or will that come from you, the owners pocket?
This is a skill that is working for others every day why not ask for help after all, you hope people hire you for your expertise.
4 – You Didn’t Have Time to Read the Small Print
The Big Print makes promises but the small print takes those promises away. When your self-funded administrator, TPA,insurer decides not to pay a claim, you’re on the hook. You as a business owner become the checkbook.
It’s true, in today’s sophisticated and complicated healthcare world it’s becoming more necessary to independently evaluate your options.
CAN YOU SAY DOUBLE TALK
This is just one example of the big print:
“Your maximum self-funding cost for the plan year is determined up front – and it’s guaranteed not to change, …
And here’s one example of the corresponding small print written into the policy of the carrier who published the “big print” quote above. There are many statements like this and you should know them all, or have someone who does.
“We issued this coverage in reliance upon the accuracy and completeness of the information provided in the application form and during the enrollment process. If a material or fraudulent omission or misstatement is made in the application form, We have the right to deny any claim, rescind the coverage and/or modify the terms of the coverage or the premium amount.”
Actual policy language, page 1.
5 – You Didn’t Make a Benefit Plan to Tell Employees They Aren’t Covered
It happens, google the topic of “self-funded plans that couldn’t pay claims” and you will find 42 million website hits (graphic below). The point is, there’s not shortage of problems for those who get in over their head.
Do you Still Need Convincing?
Show me the options in front of you and I’ll show you the trouble.
Send any quote you have received and the comparisons I’ll give you my two cents for free.
This offer is available to owners only. Send them to my email without PHI, [email protected]
Source: Actual administrator and carrier language from marketing promotions and specimen policy.