Some points on receiving medical treatment

The way we receive health care today is changing in many ways.
+ On the provider side we see lots of consolidation, which often results in higher fees.
+ The way treatment is covered by our medical benefit plans has been evolving for a few years. Implementation of federal health reform, beginning in Jan 2014, has had a big impact on increasing the cost sharing individuals have to pay.

A couple recent news posts related to these changes caught my eye:

The first is connected to the way we receive healthcare and I believe it is very important - Getting fully involved in your medical treatment.

Jennifer Thew, RN., the Senior Nursing Editor, for HealthLeaders Media brought out some points in her May 19, 2015 article, which I want to share.

I have followed the way medical treatment is delivered and have seen MDs indicating better treatment outcomes can often be gained if there is transparency on the details of a medical treatment session between the MD and patient. One part of improving this transparency, which is not always easy to implement, is to get individuals more involved in their care.

The article reported on a group of Primary Care MDs who are making the results of their visits available to patients online. She indicated in part:
“ - - - a year long study to explore how sharing clinician's notes affected care. The results found that patients frequently accessed visit notes, reported a greater sense of control and understanding of their medical issues, had improved recall of care plans, and adhered better to medication regimens.”

The study was based on a program, which is expanding, called OpenNotes. This effort will be an important step toward people receiving improved health care since in much of today’s treatment not a lot of information is available to the individual. Because of this there can be a negative impact on patients. She shared an example where the lack of information following a person’s first treatment resulted in a complicated medical situation when the situation was later found.

She also brought out a point another professional made on why it is important to get people involved:

"Another really important part of patients reading their notes is the fact that they can contribute to safety monitoring," says Jan Walker, MBA, RN, co-director of OpenNotes and assistant professor at Harvard Medical School. "Care is really complicated, we're all human, we all forget things, and having another set of eyes on what's going on can probably help people avoid errors."

Bottom line – this article provides examples on why it is so important for everyone to talk with their MDs during treatment sessions and to ask for a copy of the notes, which the MD made following the visit.

The second article was connected to to a point I communicate to client employees – A procedure performed by a high volume surgeon has advantages for them.

Cheryl Clark, senior quality editor for HealthLeaders Media reported in a May 21st article 20 hospitals have announced the "Take the Volume Pledge" campaign. Its focus, according to John Birkmeyer, MD, a surgeon, outcomes researcher, and executive vice president for enterprise support services at the Dartmouth-Hitchcock hospital, is to “reduce complications”. He indicated:

"What we're trying to do is minimize the number of patients who wind up getting their care by so-called 'hobbyists,' surgeons and hospitals that seldom do these procedures, certainly not enough to attain a high level of honed proficiency."

Cheryl Clark’s article also reported another point from Dr. Birkmeyer:

“hospitals and surgeons who perform certain procedures infrequently aren't always doing them just because it's lucrative, which it can for smaller organizations.”

"It's less because of the survival instinct and economics of high revenue surgeries. Instead, they're just accommodating the pride and professional autonomy that surgeons believe is their due. What hospitals do care about is running afoul of their surgeons and ultimately losing those surgeons who would go somewhere else."

My sense, in reviewing the article, is outcomes information on surgeries in low volume vs high volume hospitals will be developed in the future. Information and data to determine quality and outcomes is however difficult to gather and report.

In employee meetings, when discussing suggestions for doctor visits, I usually indicate when an MD says the recommended treatment for this situation is surgery it’s very important to get a second opinion. When doing this they should also seek out a surgeon that does lots of procedures like the one you are considering.

At look at – What is going on in the way we receive health care services?

I want to share some points from a report – Considering Healthcare’s Transformation. It was created following a gathering in January 2015 of healthcare executives. Specific comments made by individuals are shown in quotes. I added bold to emphasize some points I see as important to individuals.

● Much is being done to transition to value based care, which gets you and I as consumers involved in our health. About 1/3 of the providers – hospitals – physician groups indicate their concern in implementing this was “uncertainty about revenue streams”.

● The transition going on in information technology (IT) to store data in cloud based systems results in physicians thinking individuals electronic medical records (EMR) will be connected to all aspects of care.

● Consumers will be more involved in the way care is going to be managed and will “take more responsibility for health decisions".

● Surveys indicate “nearly half of consumers and 79% of physicians believe using mobile devices can help clinician’s better coordinate care”.

● Consumers are demanding more eVisits and done when they want.

● The chief medical officer at a North Carolina health system indicated – “The consumer wants to be more in the driver’s seat and less in the it’s-being-done-to-them seat as we move forward”.

● An individual from one health insurance company stated – “We work - - to move to population health in a new world order where payment structures will transition from fee-for- service healthcare to instead reward outcomes and value”.

● An MD who is a principal in the consulting firm PriceWaterhouseCooper (PwC) Health Industries Advisory service indicated – “We are now focusing on the 80% of people who are healthy, who we never paid attention to before. In the past, nobody cared if a member is healthy because as long as there is no cost and he is not sick, it’s not important. But now, because we are going to be accountable for the total cost of our population, we want to keep these folks healthy, which means we can attack the obesity problem to prevent people from getting sick and getting diabetics. That’s important”.

● The PwC MD also indicated – “My hope with the population health management approach is that we are able to bring the cost down so the financial burden is not significant on the consumer. Because otherwise we can be doing everything good but the patient is not willing to comply”.

Connecting to what the MD states, in the above comment about responsibility for treatment expenses, individuals in today's medical insurance have a larger cost share. Plans no longer just have visit co-pays. Now, to meet health reform requirements, plans use more cost sharing and a deductible. In some cases it is a deductible followed by cost sharing.

FYI - Traditional plans in CT include a provision in 2015, which limits a person's expenses during a plan year to a Maximum Out of Pocket (MOP) of up to $6,600. Health Savings Account plans follow IRS regulations and have have a MOP of $6,450.

Questions - Call my Google Voice - we can talk about things going on in CT. (860) 451-9793.

How will medical insurance plans change for the 2015 plan year?

Some details on the 2015 plans were made available in the last couple weeks which I want to share.

First some background. Federal health reform required a change in the design of medical insurance plans. IOW the deductible, co-pays, and cost sharing amounts are used in a different way. These changes began January 1, 2014.

Medical insurance plans, whether purchased in the Individual or Small Group market, have to meet certain requirements. The basics of these changes are:

● Plans must cover 10 Essential Health Benefits (EHB). Two are new to Conn. Pediatric dental coverage (for age 19 and under) and what is called habilitative services. Rehabilitative services help an individual recuperate for example following hip surgery. This coverage stops when the person is no longer improving. Habilitative coverage helps a person who is no longer improving but their condition would decline if certain services were to stop. It’s only available for certain conditions.

● Each health insurance company must use a complex calculation to determine how much of a person’s medical treatment expenses the company pays and how much an individual will pay. This calculation results in what is called the plans Actuarial Value (AV).

There are four AV levels. Platinum, which has to cover 90% of the required EHBs. Gold covers 80%, Silver is 70%, and Bronze is 60%.

A person might think when looking, for example, at a Silver plan – oh my if I have $100,000 in medical expenses I will have to pay $30,000. The answer is NO. A person’s expenses, if a major treatment situation were to occur, are limited each plan year by the maximum out of pocket (MOP) provision. This limit is adjusted each year.


Second let’s look at the highlights of a person’s coverage during 2014, who is enrolled in the Standard Silver Individual plan through Access Health CT:
● No cost for a variety of preventive exams and tests.
● A $30 co-pay for a primary care doctor visit and $45 to see a specialist
● Other medical treatment is covered after a $3,000 deductible.
● A $400 deductible on prescriptions and then a $10 co-pay for Generics, $25 for preferred brands, $40 for non-preferred brands, and 40% cost sharing for specialty medications.
● A $75 co-pay for Urgent care and a $150 co-pay for an emergency room visit.
● A $500 co-pay for outpatient surgery
● A $500 per day co-pay for hospitalization up to $2,000 is applied after the medical deductible has been met.
● A MOP of $6,350 for Single coverage. The MOP is doubled when a person enrolls one or more dependents on their plan.

Third let’s look at the highlights of Access Health CT plans for the Standard Silver Individual plan in 2015:
● No cost for a variety of preventive exams and tests.
● A $40 co-pay for up to three primary care doctor visit and $50 to see a specialist.
● Other medical treatment is covered after a $2,600 deductible.
● Generic medications will have $5 co-pays, Preferred brands at $30, and non-preferred brands at $55 with no deductible. Specialty medications will have a $60 co-pay after a $25 deductible.
● A $75 co-pay for Urgent care, after the deductible, and a $150 co-pay for an emergency room visit.
● A $500 co-pay for outpatient surgery
● A $500 per day co-pay up to $2,000, for hospitalization after the medical deductible has been met
● A MOP of $6,600 for Single coverage. The MOP is doubled when a person enrolls one or more dependents on their plan.

There may be some variation in this coverage between the health insurance companies offering these plans effective January 1, 2015.

What companies will be available for 2015? It is anticipated additional companies will apply to offer plans through Access Health CT in 2015.

How much higher will the premiums be in 2015? A BIG unknown. The Access Health CT consultants indicated the 2015 plan changes should not result in much of an increase. Of course the big unknown is what impact the every increasing cost of medical treatment will have.

Questions - send a note to - LearnMore@JohnParker.agency