Personal Injury and Social Security Disability Blog

Health Tort Reform Sounds Better Than It Is

A Daily Kos blog argued against healthcare tort reform proposals, noting medical malpractice's less than 1.5% of healthcare costs "hardly makes tort reform worthy of the attention it receives for cutting health care costs. Furthermore, tort reform has already been implemented in more than half of the states in some form," so many states would feel no impact from additional reforms. The blog cited Texas' growing healthcare costs and lead status in the number of uninsured citizens, even after implementing tort reforms in 2003. Also, tort reforms wouldn't necessarily reduce defensive medicine practices, as litigation risks will always exist, and "evidence suggests that the profit motive" from defensive medicine "would continue to drive defensive medicine practices."

Patient safety improvement key to malpractice reform. MedCity News blogger and MedPharma Partners founder David Williams wrote malpractice reform should center on increasing patient safety. In noting that "the malpractice system is going away entirely," Williams suggested shifting "some or all of the savings to education and re-engineering of care processes to improve patient safety in order to prevent the emergence of situations that the malpractice system is meant to address." He cited a Boston Globe op-ed highlighting the danger posed to patients that result from a lack of coordination between doctors. He also challenged arguments that lawsuit fears lead to defensive medicine by suggesting the practice could be a function of patient preference. He added, "A much bigger impact on unnecessary tests will be had by shifting the payment system toward capitation."

From the American Association for Justice news release.

Ten Costly Mistakes to Avoid When Applying for Medicare

The annual enrollment period for Medicare runs through the month of December. For those who have not yet made a decision, here is a list of ten mistakes to avoid, provided by PlanPrescriber, a subsidiary of eHealth, Inc.

10 Costly Mistakes That Seniors May Make During Medicare Annual Enrollment Period

(1) Missing the Fine Print: Don't ignore the fine print in your annual Notice of Change about which benefits have changed and which have remained the same for your plan in the new year.

(2) Going on Auto-pilot: It may not be the best idea to simply auto-enroll in the same plan. Many plans change their costs and drug coverage annually. What worked last year for you may not work with the same plan this year and could cost you money in terms of higher prescription drug costs and other out-of-pocket expenses. Changes in medication usage can also change what plan offers you the best economic value.

(3) Assuming that Stable Premiums = Stable Coverage: Just because your Medicare Advantage or Part D premium hasn't gone up doesn't mean that you are getting the same plan for the same price next year. Deductibles, copayments, and prescription drug coverage are just a few of the benefits that may have changed. Research and find out what the total out-of-pocket cost will be for the new year's plan.

(4) Not Asking for Help: Qualified professionals can help you understand your options and select a plan, and there are also tools available to help you evaluate your prescriptions. You can get help through your State Health Insurance Assistance Program (SHIP), www.PlanPrescriber.com, licensed health insurance agents who are certified to sell Medicare, or by calling 1-800-Medicare.

(5) Not Getting a Second Opinion: By not shopping around and seeing what other plans are out there, you may be costing yourself more money in 2011. This is an important decision, so take the time you need to make the right choice and understand all of the options available in your area.

(6) Overlooking Extended Care: Don't assume nursing home care is a covered benefit; it is not. Medicare does not provide coverage for custodial care, assisted living facilities or long term care. However, skilled nursing facilities may be covered following a related hospital stay.

(7) Assuming Your Drugs Are Covered: Don't assume your doctor knows which prescriptions are in your formulary. You can enter your current medications on a website like www.PlanPrescriber.com to see which drugs are covered on your current plan and compare the projected costs with other plans available in your area. You can print out this comparison and take it with you to see the doctor. Make sure your doctor knows your in-network labs, physical therapists, or durable medical equipment suppliers too.

(8) Assuming Medigap Has You Covered: Don't assume Medigap plans will pay claims that Medicare won't. Medicare only pays for medically necessary claims. If Medicare doesn't pay, either because the service rendered is not a covered benefit or is not considered "medically necessary," neither will the Medigap plan.

(9) Assuming You'll Qualify for Medigap: Don't assume you will automatically be accepted in a Medigap plan outside of Open Enrollment or guaranteed-issue-qualifying events. Medical underwriting does occur. Work with a licensed agent for help.

(10) Assuming You're Covered World-wide: Medicare will not pay medical claims outside the United States and its territories. However, certain Medigap plans might extend emergency coverage outside of the United States.

Medicare beneficiaries can use PlanPrescriber's plan comparison function to review every Medicare Part D and Medicare Advantage plan available nationwide, and those interested in plans offered by UnitedHealthcare, Humana and certain other Medicare carriers now have the opportunity to enroll in many of these plans online. Customer support from licensed eHealth agents is available by telephone seven days a week from 5am-5pm Pacific Time at 888-832-5927, TTY 888-407-5794. Medicare beneficiaries using PlanPrescriber can also contact licensed agents and representatives for personal assistance by email or online chat.

 

Victory for Texas Consumers in Health Insurance Rule Change

In an important and increasingly rare victory for Texas consumers, the Insurance Commisioner, Mike Geeslin, has declared that insurance companies can no longer use "discretionary clauses" in certain policies. This new rule will apply to life, disability, and health insurance, but not to automobile liability insurance.

A discretionary clause essentially gives an insurance company the right to unilaterally decide what the policy covers, and therefore what benefits, if any, should be paid. What this has meant in the past is that regardless of what the insurance agent told you when you bought the policy, and regardless of what seemed to be clear language in the policy, when you filed for benefits you might simply be told that the insurance is not going to pay.

Mr. Geeslin, in announcing the rule change, said that the discretionary powers of companies "are unjust, encourage misrepresentation and are deceptive because they mislead consumers regarding the terms of coverage" in their policies. The new rule, according to the commissioner, will shield Texas consumers from "incorrect and unfair coverage determinations by insurers and HMOs without a subsequent opportunity for a full and independent review" of their claims. Policy holders now will be able to challenge unfair denials of benefits, either by complaining to state regulators or by filing suits against the insurance companies.

Here is a press release from the Office of Public Insurance Counsel, which pressed for the rule change:

Insurance Commissioner Adopts OPIC’s Rules Prohibiting Discretionary Clauses in Insurance Policies

The Texas Commissioner of Insurance adopted three rules proposed by the Office of Public Insurance Counsel prohibiting discretionary clauses in insurance policies on Friday. Discretionary clauses are contract provisions that provide insurers with sole discretion in deciding if, when, and what benefits are due under the insurance policy. The existence of these provisions alters the way courts review insurer’s decisions on appeal, and make meaningful reviews of an insurer’s decision virtually impossible. In prohibiting discretionary clauses Commissioner Geeslin wrote [d]iscretionary clauses are unjust, encourage misrepresentation, and are deceptive because they mislead consumers regarding the terms of coverage.”

Public Counsel Deeia Beck said that her agency proposed these rules to “assure that health and life insurance benefits are contractually guaranteed, and to avoid the conflict of interest that occurs when the carrier responsible for providing benefits has discretionary authority to decide what benefits are due.” Members of the Texas Legislature, the American Association of Retired Persons, the Texas Medical Association, the National Multiple Sclerosis Society, the Center for Public Policy Priorities and many others were instrumental in getting the new rules adopted. Ms. Beck said, “It was a privilege and honor to work with these fine people to ensure that Texans will receive the full benefit of the insurance coverage they purchase. I greatly appreciate Commissioner Geeslin’s hard work and decisiveness in adopting these strong rules.”

The new rules take effect on February 1, 2011 for some types of disability insurance, and June 1, 2011 for all other forms of health, life, and disability insurance policies issued in Texas. Twenty-three states and the National Association of Insurance Commissioners have now adopted statutes, rules, or policies prohibiting discretionary clauses. 

Insurers Gave U.S. Chamber of Commerce "Breathtaking" Sum to Combat Obama Health Care Law

Bloomberg News reported that the national insurance member group America's Health Insurance Plans, armed the US Chamber of Commerce with $86.2 million "that was used to oppose the health-care overhaul law." Bloomberg notes, "The spending reflects the insurers' attempts to influence the bill, which the Congressional Budget Office estimates will provide coverage to 32 million previously uninsured Americans." Washington attorney Trevor Potter said "By funneling the money through the Chamber, insurers were able to remain at the table negotiating with Democrats while still getting the bill criticized. 'It enables you to have it both ways.'" The White House criticized the donation, describing insurers as "desperate to preserve their ability to discriminate against you if you had a preexisting condition, drop your care when you got sick and limit the amount of care you could receive in a year or a lifetime."

From the American Association for Justice news release.

 

Blue Cross Blue Shield Sues Pfizer Over Drug Marketing and Illegal Kickbacks

Blue Cross Blue Shield of Texas, which is the largest health insurer in Texas, has filed suit in federal court in Texas against Pfizer Inc. for deceptive marketing of drugs and for illegal kickbacks to doctors.

The suit alleges that Pfizer promoted the sale of Bextra, an anti-inflammatory drug, for several uses that the government had declined to approve because of safety concerns. Pfizer also is accused of illegally promoting two other drugs – Geodon, an antipsychotic, and Lyrica, an anti-epileptic drug.

Blue Cross is claiming that it lost money because it paid for prescriptions that should not have been written. Pfizer denies the allegations, but settled a similar case with the federal government and more than 40 states last year. In that case, Pfizer agreed to pay $2.3 billion, the largest health care fraud settlement in the history of the Justice Department, to resolve similar allegations.

Featured Link - Consumers Guide to the Health Reform Bill

This summary of the health care reform bill passed by the House yesterday is very readable. I can't vouch for the accuracy of all the information here, but I didn't notice any glaring errors. It's a good starting point for those who want more information about the effect on them of this historic legislation. The summary is from Kaiser Health News.

Obama Health Proposal Could Reduce Texas Insurance Premiums

It may come as a surprise to those not familiar with Texas politics that Texas does not review most increases in health insurance premiums. Not unless the premium increase is for more than 50% annually. Everything else is fair game. An insurance company can increase premiums 49% per year every year and that would be fine with the State of Texas.

But now we have a health care proposal from the Obama administration that would allow the federal government to review "excessive" health insurance premium increases. The federal government would be able to stop a rate increase it considered unjustified. Whether this is government intervention or consumer protection depends on your point of view, and maybe on whether you're a health insurance company executive.

Soaring Premiums Show Need for Health Care Reform

Kathleen Sebelius, U.S. Department of Health and Human Services Secretary, has written an opinion piece in the Atlanta Journal Constitution in which she says the recent proposed rate increase by Wellpoint and Blue Cross is evidence that fast reform is needed in this country's health care system. Here are excerpts from the article:

Earlier this month, families opened their mail to another stark reminder of why we need to reform our broken health insurance system.

In California, beneficiaries of an insurance company owned by WellPoint called Anthem Blue Cross received letters announcing that their premiums would rise as much as 39 percent, meaning a family paying $1,193 a month will now owe $5,580 more on its annual bill.

Even more infuriating for the people receiving these letters, this increase didn’t happen because WellPoint had fallen on hard times. WellPoint recently announced more than $2.7 billion in profits from the most recent quarter alone.

It’s outrageous that insurance companies are reaping huge profits on the backs of working families who are already struggling to make ends meet. It’s also all too familiar.

Even as a recent report showed that America’s five largest insurers made over $12 billion in profits last year with their CEOs taking home up to $24 million each, some of those same companies have requested significant premium hikes.

In the last year alone, insurance companies have requested premium increases of 56 percent in Michigan, 24 percent in Connecticut, 23 percent in Maine, 20 percent in Oregon and 16 percent in Rhode Island.

Right now, our health insurance system works well for insurance companies. They can raise your premiums or slash your coverage, knowing it’s hard to find another plan.

In most states, they can turn you away if you have a pre-existing condition like high blood pressure. They can even cancel your coverage when you get sick. All they have to do is find one error in your paperwork.

Meanwhile, families get a raw deal. They usually have very few plans to choose from. Often, the choice is between one plan they can’t afford and another plan that offers threadbare coverage. That’s assuming families make it through all the fine print to actually find out what a plan does and doesn’t cover.

The reason President Barack Obama started working on health insurance reform early last year was to put these families and their doctors and nurses back in charge of health care decisions. Throughout this process, we’ve been driven by a few simple goals.

First, we need to slow the growth of rising health care costs for families, businesses, and government, so that workers can start getting raises again, companies can start growing, and we can finally start bringing down the deficit.

Second, we need to strengthen insurance for the Americans who already have it. That means creating new rules for insurance companies to stop them from putting an artificial cap on your benefits or canceling your policy when you get sick.

Third, we need to make affordable coverage available to every American. Markets work, but only when there’s competition and real choices. So we need to create a health insurance market where every American has quality, affordable options.

With those basic principles guiding their efforts, both houses of Congress have made history by passing reform bills for the first time ever. But until a final bill reaches the president’s desk, Americans will continue to see rising premiums and shrinking security.

The premium hikes in California and across the country are a wake-up call. It’s time for Congress to pass reform and hand control over health care decisions back to American families and their doctors.

Featured Link — Texas Health Pool

The Texas Health Pool is a health insurance resource of last resort for people who can't find coverage anywhere else. Many questions about this pool are answered on the site's FAQ page. Here is the Pool's self-description:

The Texas Health Insurance Pool was created by the Texas Legislature to provide health insurance to eligible Texas residents who, due to medical conditions, are unable to obtain coverage from individual commercial insurers.  The Pool also serves as the Texas alternative mechanism for individual health insurance coverage, guaranteeing portability of coverage to qualified individuals who lose coverage under an employer group plan, church plan or state plan, as mandated by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Program continues to serve the State of Texas as an important "safety net" for individuals who have been denied health insurance coverage because of pre-existing conditions, can afford the Pool's premiums, and do not have other coverage options.

The Texas Health Insurance Pool was created by the Texas Legislature to provide health insurance to eligible Texas residents who, due to medical conditions, are unable to obtain coverage from individual commercial insurers.  The Pool also serves as the Texas alternative mechanism for individual health insurance coverage, guaranteeing portability of coverage to qualified individuals who lose coverage under an employer group plan, church plan or state plan, as mandated by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Program continues to serve the State of Texas as an important "safety net" for individuals who have been denied health insurance coverage because of pre-existing conditions, can afford the Pool's premiums, and do not have other coverage optio

"Tort Reform" Won't Fix Health Care

In an op-ed article in the Baltimore Sun, attorney Wayne M. Willoughby makes a convincing argument that "tort reform" is not the solution to high healthcare costs. Here are excerpts from the article:

For months now, national Republicans and their media supporters have attempted to divert the health care debate away from improving access to quality health care. Instead, they call for legislation stripping away the rights of injured patients. Over a half-dozen such amendments have been introduced by Senate Republicans so far this month.

As any former supporter of "tort reform" can tell you once he or she becomes seriously injured by medical negligence, such reform sounds grand in the abstract. "Those people" should not be getting "all that money." However, when you (or your spouse, child or parent) are the injured patient, tort reform is no longer an abstraction involving "those people" - it is about being denied basic fairness.

The Institute of Medicine found 10 years ago that up to 98,000 people die every year from preventable medical errors, and countless more are severely injured. This is the equivalent of two 737 planes crashing every single day.

If air travel were this unsafe, who would shoulder the blame - the passengers or the airlines? Would any politician dare to claim that we should limit the legal rights of passengers in order to protect the airlines and lower ticket prices? Of course not; they would be clamoring to enact laws to improve flight safety. Yet, when it comes to health care, Republicans on Capitol Hill offer the snake oil of tort reform instead of pushing for greater safety.

Citizens should demand that politicians pursue a different model of reform - one that places the priority on increasing patient safety rather than on insurance company profits. The proponents of "tort reform" should join with the proponents of health care reform to enact legislation to eliminate preventable medical errors. If preventable medical errors that injure tens of thousands of patients each year are significantly reduced, the result would be both a substantial increase in patient well-being and a substantial decrease in malpractice actions - all while protecting the rights of those with legitimate claims.