For Employers Held Hostage by Managed Care Companies - A Plan of Escape

Despite healthcare reform debate, rising medical plan costs continue to pummel U.S. employers. Corporate health plan costs are projected to increase again this year by more than 6%*. Since 1999, costs have increased by 134%**, nearly five times the cumulative rate of inflation.

Ironically, during this same 10-year period, private health insurers posted record profits, while holding their employer-clients as hostages, feeding them only soaring costs, poor service, and lots of excuses.

But one major east coast company escaped the hostage situation and just celebrated its 8th straight year without a medical cost increase. In fact, while other companies reduced benefits to lessen crippling rate increases, this employer, whose medical plan covers 45,000 lives, actually enriched its benefits program. Today, its annual health plan costs per employee are 60% below the national average.

These astonishing results were achieved without a major insurance company's help. The employer simply eliminated the managed care middleman entirely and contracted directly with doctors and hospitals.

Cutting out the middleman is an age-old idea, but when it comes to employer health plans, insurance carriers still hold employers hostage. Large managed care networks, controlled by profit-bloated and increasingly monopolistic private insurers, have emerged as the only means of coverage for employers. They're also the dominant source of patient revenue for doctors and hospitals, so medical providers are held hostage, too. Consequently, the middleman controls both sides of the healthcare equation and effectively prevents buyer and seller from doing business directly with each other.

Though highly effective, direct contracting is still largely unknown to CEOs whose companies are held hostage. Whipsawed by relentless cost increases, their benefit departments still rely on profit-centric insurance companies for cost-containment strategies, most of which are based on conventional managed care networks and cost-shifting onto employees. As true hostages of the big carriers, employers have been effectively brainwashed into believing there's no viable alternative to the carrier's approach. They're convinced that if the big insurers like Blue Cross, United Healthcare, Cigna, and Aetna don't have the answers, no one does. But direct contracting proves otherwise.

Direct contracting creates a "win-win" business relationship between employer and medical provider, the true "buyer" and "seller" in the managed care equation. By cutting out the managed care middleman, the employer and provider eliminate the inherent disadvantages and financial shortcomings found in commercial managed care contracts. The direct agreement saves the employer money without shortchanging the medical provider. It creates a strong, stable, long-term, and mutually beneficial business relationship.

Employer-owned networks are comprised of doctors and hospitals that provide medical care according to the employer's health plan. For instance, the east-coast employer mentioned earlier has direct contracts in place with more than 10,000 physicians and 80 hospitals across 15 states. Direct agreements give employees and dependents easy access to medical care, while paying those providers quickly, fairly, and without administrative hassle.

Direct contracting bears no resemblance to the complex, adversarial, and financially disadvantageous network agreements forced upon medical providers by insurance companies. Direct networks truly unite physicians and employers in the goal of providing accessible and affordable medical care to employees, without the obstacles and costs found in commercial PPO networks.

As an alternative to HMOs, PPOs, and other commercial managed care approaches, direct contracting is a proven solution for employers who are desperate for relief from soaring costs. For employers held hostage by insurance carriers, direct contracting is a bold plan of escape. However, for such a plan to work, it requires strong executive-level leadership and a willingness to take risks along the way. But for those companies that do, the rewards of freedom from the carriers can mean huge savings, happier employees, and better control over future health plan costs.

* According to Towers Perrin's 2009 Health Care Cost Survey, the average corporate health benefit expenditure in 2009 will be $9,660 per employee--an increase of 6% over 2008 figures.

** Kaiser Family Foundation Employer Health Benefits 2009 Annual Survey.

Howard "A.J." Lester is president of A.J. Lester & Associates, Inc, a leading employee benefits consulting firm based in Houston, TX that helps major employers reduce health plan costs by developing directly contracted medical provider networks as an alternative to commercial PPOs. Since 1994, A.J. Lester has developed direct provider networks for well-known national employers across 35 states, negotiating agreements with nearly 80,000 physicians and over 800 hospitals on behalf of clients. A.J. Lester & Associates has helped its clients save tens of millions of dollars on their health benefit programs.

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Our "Sicko" Society

As a regular commentator on the state of Disaster Preparedness and corporate healthcare responsibility in the United States as well as an ardent defender of healthcare professionals, their needs and their very lives, I was both honored and a bit taken back when asked by several medial journals to attend and review Michael Moore's documentary "Sicko". I was the immediate recipient of much ribbing from colleagues, even receiving a prescription, just 32 milligrams of Zofran to be taken immediately before the movie; this from an oncologist who reminded me that Zofran is the drug of choice in preventing chemotherapy related nausea and vomiting, "if it can handle chemo, it can handle Michael Moore."

By total coincidence and an ironic twist of fate, I served federal jury duty the day I saw the movie and took an oath to hear all evidence before me without prejudice or preconception. Having being released from jury service by noon, I girded myself in that oath and drove to the theater. Plopping down my $7.50 for the ticket and $10 for popcorn and a large water bottle, I strode in air conditioned comfort to theater 8. The theater itself was virtually abandoned, despite the fact that I had chosen to attend the movie at Walt Disney World's Downtown Disney AMC Theatre at the height of tourist season. I had expected the theater to not only be full but to be filled with people who are ardent supporters of Mr. Moore and his films. I must admit I would not be among them. Quite to the contrary, I had not seen a Michael Moore film in a number of years. I do enjoy the occasional documentary and own a copy of Super-Size Me which I still recommend to patients, but Mr. Moore's story telling style is, well let's say it is not to my taste.

Within the first moments I found myself confronted with an uncomfortable fact, Mr. Moore's movie was attacking the same Heavily Mangled-care Organizations (HMO's) that were in large part the very reason that I had left private to practice. Everything that Mr. Moore said about such large organizations as Aetna, Cigna, Humana and Kaiser were true. Of course in invertible Michael Moore fashion he told only one side of the story, paying only passing homage to the fact that five-sixth of the US population do in fact have healthcare coverage and that out of 300 million people in the United States, most of whom have Internet access, he received fewer than 80,000 replies to his solicitation for healthcare horror stories. Still, Mr. Moore was actually making sense.

Unfortunately, also in an inevitable Michael Moore fashion, he quickly snatched defeat from the jaws of victory. The totally incomprehensible detour to a cold war era campaign by the American Medical Association to speak specifically against the evils of socialists and communists in medicine was juxtaposed against the Clinton era's attempt at Universal Health Care. Mr. Moore seems to have missed the fact that now New York Senator Hillary Rodham Clinton stated emphatically throughout her term as chair of National Healthcare Committee that Universal Health Care was not a socialized healthcare system.

Mr. Moore also seems to have forgotten the historical context in which the American Medical Association launched its anti-socialist campaign in those early days of the cold war. Communist fears gripped the nation for over twenty years and every "respectable" professional or fraternal organization "did its part" to combat the so-called Red Menace. The American Medical Association's campaign against socialist medicine was a political statement against socialism and communism not against Universal Health Care.

Although I am a physician I do have the unique perspective of not being a member of the American Medical Association. In fact, at the same time that the American Medical Association was actively attacking socialists and communists in healthcare; they were also attacking my profession of osteopathic medicine and therefore if anyone would support Mr. Moore's attack on the American Medical Association it should be me, a member of the American Osteopathic Association. Just as I swore earlier in the day to objectively hear the case against the defendant in federal court I must now objectively evaluate the arguments made by Mr. Moore and in the case of the American Medical Association Mr. Moore's arguments fall far short of any form of reality.

Returning to the main theme of the movie (corporate greed as the oppressor of the people) Mr. Moore next attacked the profits and policies of the pharmaceutical industry. The donations to prominent congressional members and others in government were enlightening and even entertaining in their presentation, but there was no new news here. The Food and Drug Administration and even Congress itself has decried these practices for years.

Mr. Moore then took a brief trip around the existing Socialized Medicine Programs in Canada, Great Britain and France. He went to great lengths to describe their advantages, speaking to Americans who thought that they benefited from a socialized medicine system in which they had no need for insurance and no need to pay copay's. He also spoke with fully satisfied individuals living in Canada and Great Britain.

Mr. Moore's interview with one British doctor was quite enlightening. On screen I met a physician whose entire education had been paid for by his government and his government was generous enough to pay him a salary equal as a family practitioner equal to what I make as an emergency department physician. Although, I am board certified in family practice as well as emergency medicine, I never made as much in US dollar equivalents as this young man makes now. This London doctor lives in a four-bedroom home worth twice as much as my home and drives a car worth four times as much as my car. He has these benefits not because a socialized medicine system works better or even pays better but because he was the beneficiary of socialized education through graduate school. I labor under student loan payments that almost equal my mortgage payment and will do so for a thirty-year period of time. If I had the benefits of free education, I too could live in a home worth over a million dollars, although I would still drive my Saturn because quite frankly I like it.

Mr. Moore's tour then took an unusual direction clearly designed to draw publicity rather than make any specific point. Mr. Moore took several 9/11 survivors and delivered them to Cuba in order to receive treatment for 9/11 related injuries and illnesses. Mr. Moore claims he did this because he had found an American "socialized medicine" system at Guantanamo Bay, Cuba and just wanted 9/11 heroes to receive the same medical benefits as Al Qaeda. Why not take these heroes to a state prison in Florida? The almost every state correctional institution in the United States, inmates receive the same or better care than the detainees at Guantanamo Bay. Again Michael Moore missed the mark.

I find it curious that while in Canada, a country that is accustomed to American film makers and quite frankly Americans sneaking across the border to obtain free healthcare, Mr. Moore and his would be American patient for the Canadian system found it necessary to flee Canadian police at two separate clinics in order to avoid arrest, yet in Cuba, a country well known world-wide to embrace its tourists but to be highly suspicious of those with professional movie making equipment, Mr. Moore appeared to never encounter a police officer. In fact Mr. Moore was allowed to photograph throughout the state-run Havana Hospital, the very same hospital where Cuban leader Fidel Castro received his recent medical care. Further Mr. Moore was miraculously permitted to photograph in and around a Havana fire station, exchanging gifts and even souvenir badges with fire brigade members. I find it equally interesting that these badges were conveniently available.

Mr. Moore, who appears throughout the movie, to this point, to be very upfront with the challenges and special arrangements made in the production of his film seems to leave out the fact that he doubtless had special dispensation from the Cuban government allowing both for his film making and the care of Americans on Cuban soil.

Despite these glaring inconsistencies, I was thrilled when the Cuban doctors began to touch on the issue of the relationship between the system and the healthcare professional. I thought that Mr. Moore was finally going to disclose American Healthcare's greatest shame, the total annihilation of the nurturing relationship between healthcare professionals and their corporate masters. But alas, Michael Moore again shied away from the issue... why?!

An interesting conversation took place recently between a 45 year nursing veteran and her family. The topic of the day was the nursing shortage and the veteran nurse surprised all by announcing, "There is no nursing shortage, there is a hospital nursing shortage."

She went on to explain that in the home health and non-institutional nursing fields, there is an adequate supply of nurses willing to work for employers who respect and value their services. According to this nurse who had worked in hospitals for much of her career, the problem today is that hospitals and other institutions see nurses and other professionals as replaceable rather than precious.

"No nurse my age is going to work for some young supervisor who believes that you manage people by threatening them or their license. There are too many jobs out there to deal with that nonsense."

This veteran nurse struck on the key factor in any employee shortage, the relationship between employer and employee.

Healthcare has become a split marketplace with institutional care (hospitals and nursing homes) separated from non-institutional care. Nurses are gravitating to non-institutional care despite lower pay because of the factors that Intuit and others have come to appreciate. Employees care more about the relationships than the money. Veteran nurses remember being respected and appreciated for long hours and selfless dedication. It was not expected or required, it was given freely and accepted graciously. Even in a "materialistic society" people want to be loved and cared for, respected and valued.

There is no nursing shortage, there is a relationship shortage. This is the true problem with corporate healthcare in America.

All and all I will say that Mr. Moore's film was an honest review of the current state of the Heavily Mangled-care in the United States. Greedy insurance companies take from doctors in the form of Malpractice Coverage. They take some patients in the form of health coverage; they raise profits through denials of care, restrictive practices, penalties against physicians who place patient care and safety ahead of performance numbers and by seeking to exclude those who most need insurance.

Sadly, the majority of Mr. Moore's movie missed the point. American healthcare will not be served by the conversion to a socialized medicine system. Quite to the contrary most of the equipments seen in background of Mr. Moore's movie was invented, designed, manufactured, or funded by the America's private healthcare industry. American healthcare would be best served by rebuilding relationships with the most valuable resource in healthcare, the healthcare provider. All those Mr. Moore interviewed told stories of having a favorable relationship with a system which they respected and which respected them. Regardless of whether you are a healthcare professional or a healthcare consumer, the basis of the process of healthcare is a relationship based on mutual respect, the system delivering that healthcare must live by that standard as well.

Socialized medical systems certainly have their advantages for citizens of countries willing to live with different freedoms and different lifestyles than we prefer in America. A better system is out there, we need only have the resolve to find it.

Mr. Moore also falls significantly short in failing to make note of the reasons that so many Americans require so much healthcare. Even a man with only a high school diploma such as Mr. Moore must ask himself if five-sixth of the United States population have health insurance, then why do individuals in other countries live longer than we do. Perhaps it is because we also have an excess of food, an excess of cars, an excess of conveniences. United States longevity for it's citizens and disease rates among its most vulnerable are so high not only because people put off necessary healthcare for fear of incurring debt, but because they chose instead to indulge in fast foods which are too high in salt and fat, drive rather than walk or bicycle for short errands, play video games rather than exercise, and finally watch movies about what others do rather than going out and doing something themselves.

As I watched the corpulent Michael Moore striding down the streets of London and France being passed by much thinner Europeans, I could not help but be struck by the fact that it is not our healthcare system, but our societal values that are truly "Sicko." It is time we all put down our popcorn, take our water bottles and go outside to exercise with our children.

Dr. Maurice A. Ramirez is the founder and president of the consulting firm High Alert, LLC.. He serves on expert panels for pandemic preparedness and healthcare surge planning with Congressional and Cabinet Members. Board certified in multiple specialties, Dr. Ramirez is Founding Chairperson of the American Board of Disaster Medicine and serves the nation as a Senior Physician-Federal Medical Officer in the National Disaster Medical System. Dr. Ramirez has a new book: You Can Survive Anything, Anywhere, Every Time. His website is http://www.High-Alert.com

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Three Warning Signs That Our Country is in Real Trouble

Countries and systems don't fail overnight. There are warning signs. Red flags precede any kind of a decline.

Usually, these warning signs are dismissed as temporary obstacles on the road to unending success as we go whistling past the graveyard. Until one day the bottom falls out without any apparent warning. The red flags were always there - it's just that nobody paid attention.

This first warning sign is a systematic decline in values to the extent that human suffering and inequities mean less than money. The scramble for money has already become so intense that physicians refuse to see sick people if their insurance isn't quite right (doesn't pay enough) such as Medicare, and even includes large companies like such as Aetna, and United Health Care if they try to control costs too closely.

This insensitivity is called greed. Money rules the game, and all pretenses of caring for our fellow men and women go out the window. Even though the insensitivity is rationalized by the "tongue in cheek" argument that the more money there is, the better off poor people will be, this has proven to be a huge fallacy. The rich get richer and the poor get poorer until the system crashes. The latest financial crash and "recovery" is a sign that this kind of greed mentality has taken root at an intractable level; all the old abuses are coming back, and fast! Ponzi schemes eventually fail, and gamblers can never get enough.

And it will worsen. Greed is already permeating society at every level. Why is it that our companies in this country, unlike other countries where health care costs are spread evenly throughout the populace, are stuck contributing up to seventy-five percent of the health care cost? This is killing them as greed increases medical costs two or three times that of wages. How could anyone blame small and large companies when they replace full time workers with part time workers to avoid offering health insurance, or how could we blame them for not offering health insurance at all?

Greed will continue to grow with the health care industry at every level - doctors, hospitals, insurance companies - and as the back-breaking costs to the employers increase, they will have no alternative other than to cease and desist in all health care contributions to employees, which means that the health care industry will eventually price itself into oblivion.

All these cross-currents can be readily seen the current fractionalized health care debate where money and institutions are considered more important than the well being of all Americans. It is all playing out perfectly regarding this first warning sign of greed, and greed will certainly be a major contributing factor to the eventual fall of the system as we know it. Money and influence rule the lives of the common man and woman now, rather than compassion and caring. And historically, that was a sure sign of any cultures eventual decline.

The second warning sign is hatred. If you look back over the history of our country, never has there been such openly expressed hatred toward those with dissenting opinions. It has deteriorated to the point that the president is no longer respected, cannot even civilly talk to school children without a violent reaction from the other side. This all indicates a deep and intractable hatred that is festering and will eventually ruin the country. This is a national Hatfield's and McCoy's. Can actual violence be the next move? Apparently; when men in congress can outspokenly call each other liars, violence can't be too far off.

And the third warning sign is our delusion regarding who we are as Americans. The world has an opinion of who we are, but our own opinions of who we vary dramatically from outsiders who can objectively see what we are. While we see ourselves as fiercely independent, which is a consolation that results from a run of exceptionally good luck for a young (200 + years) country, the world at large sees us as arrogant, egotistical, spoiled, greedy, and insensitive to the world at large and even our fellow citizens, where America is living off of the world's back by borrowing money that we will never be able to pay back, in order for us to live rich and famous lifestyles far beyond the means of other countries.

But there is still time to save ourselves. Greed to get what we want regardless of everyone else - hatred of anyone who disagrees with us as if we know it all - and delusion about who and what we truly have become can all be cured. The problem is that the cure will entail a complete failure of the system before anything or anyone will change. This is the way we seem to run things here, complete ignorance to what is going on until it is too late - because no one can tell us what to do, and we refuse to take any advice. Are we fiercely independent? Or fiercely stupid?

Open mindedness and considering all alternatives would be the way to change things without an eventual failure of the system, but that probably won't happen. Large egos, closed mindedness, stubbornness - all will prevail if history has any relevance. So, as the oil filter company says, "You can pay me now or pay me later," we can start to set things right before they collapse and get back to our original values as a country, which were humility, hard work, freedom, consent and dissent, equality and equity, due process, toleration, privacy, the common good, and cooperation and compassion for each other, or we can continue down a road of selfish greed, hatred and delusion.

Whatever we decide - it must begin with the person reading this article.

anagarika eddie is a meditation teacher at:

http://www.dhammarocksprings.org/ and author of "A Year to Enlightenment"

His 30 years of meditation experience has taken him across four continents including two stopovers in Thailand where he practiced in the remote northeast forests as an ordained Theravada Buddhist monk.

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Is US Medicare Coverage in the Philippines Possible?

Between 2007 and 2008, rumors and reports came out that U.S. Medicare coverage in the Philippines is possible. Generally, U.S. Medicare coverage is limited to all 50 states. Has Medicare gone portable at last? This article explores the truth behind the talks.

A Look Back

Sources estimate that out of the 4 million legally staying Filipinos in America in 2008, approximately 80 percent hold U.S. citizenship and a number are covered by Medicare.

Medicare is America's federal health insurance program. It was first created in 1965 to benefit citizens aged 65 and older. In 1972, the program was revised, allowing younger people with Lou Gehrig's disease, permanent disabilities and end-stage renal health complications to enroll.

Understanding the Structure

Medicare is a collective term that may include a number of plans:

* original Medicare that provides hospital insurance and medical insurance
* Medicare Advantage that provides both basic and extra healthcare services, as offered by private health maintenance organizations (HMOs) and
* prescription drug plans that may or may not be tied to a Medicare Advantage plan

Additionally, there are Medigap plans to supplement what original Medicare does not cover. They are offered by private insurance companies.

The current policies are lettered C to J. However, in a fact sheet released by the Department of Health and Human Services of the U.S., new Medigap plans M and N will replace plans H, I, E and J starting June 1 of this year.

Off-Shore Medicare Coverage in Theory

Under the original plan, the circumstances that allow Medicare portability are limited. Coverage outside America is permitted whenever a foreign hospital is nearer than any other hospital on American soil. In rare emergency cases, those traveling "without unreasonable delay" through Canada may also avail of off-shore coverage - provided again that the Canadian hospital is much closer than an American hospital.

In March 2010, the Department of Foreign Affairs of the Philippines confirmed that under the original Medicare plan:

"... Residents of Guam and Saipan... are allowed to seek medical treatment... on emergency cases, availing of their Medicare benefits in Philippine medical facilities, due to the proximity of the Philippines vis-a-vis Hawaii, the nearest US state."

This development is credited to the efforts of Madeleine Bordallo, congresswoman of Guam, and of Roberto Romulo, former Department of Foreign Affairs secretary, who lobbied that Philippine hospitals be allowed to issue Medicare reimbursements.

Off-Shore Medicare Coverage in Practice

My Philippine Retirement made a round of phone calls to check whether hospitals in the Philippines have already reimbursed Medicare benefits under the original plan. There were no recorded cases yet, the staff said. In fact, majority of the hospitals appeared to be unaware of "U.S. Medicare."

They did supply the following list of honored international health insurance plans, some of which have tie-ups with Medicare Advantage plans:

LIST A.International Health Insurances Honored in Selected Luzon-Based Philippine Hospitals as of March 2010

* (Allianz) Worldwide Care - Asian Hospital
* AETNA - Asian Hospital
* AETNA Global Benefit - Makati Medical Center
* Alliance - Asian Hospital
* Blue Cross International - Asian Hospital
* Blue Shield - Asian Hospital
* Calvo's - St. Luke's Hospital
* CIGNA - Asian Hospital
* GMC Services - Makati Medical Center
* HTH World Wide - Makati Medical Center
* IMA - Makati Medical Center
* IMG - Asian Hospital
* International Health Insurance of Denmark - Makati Medical Center
* International SOS - Makati Medical Center
* Net Care - Asian Hospital, Makati Medical Center
* Pacific International - Asian Hospital
* Prestige International - Makati Medical Center
* StayWell - St. Luke's Hospital
* TakeCare - Asian Hospital
* TieCare - Asian Hospital, Makati Medical Center
* Vanbreda International - Asian Hospital, Makati Medical Center
* William Russel - Asian Hospital

Availment of insurance benefits varies by health maintenance organization (HMO), insurance plan and servicing hospital. The insured must inquire about their Medicare Advantage benefits by HMO or plan name. Specific concerns may be sent to the respective customer care and credit/billing departments of the hospital.

LIST B. Contact Information of Selected Philippine-Based Hospitals that Honor International Health Insurances with Possible Medicare Advantage Tie-Ups

* Asian Hospital and Medical Center: info@asianhospital.com * +63 (2) 771-9000/ +63 (2) 876-5838
* Makati Medical Center: sales@makatimed.net.ph * +63 (2) 870-3000/ +63 (2) 870-3008
* St. Luke's Hospital: info@stluke.com.ph * +63 (2) 723-0101/ +63 (2) 723-0301

Impact on Philippine Retirement Decisions

The affordability of healthcare services in the Philippines is somewhat let down by the "pay-as-you-go" system, but a recent turn of events are changing the way potential retirees view the minor "cash first" inconvenience.

One such development is the direction that Medicare portability is headed. Statistical trends indicate that by 2011, Medicare expenditures will soon exceed the revenues generated from the trust fund. This can be prevented when cheaper off-shore facilities are used to deliver the same-quality healthcare services offered in the U.S., experts explain.

Another development is the health reform bill on patient protection and affordable care that U.S. President Barack Obama signed in March 2010. The current reform permits off-shore coverage and insurance of people with pre-existing health conditions. There will also be a minimum annual tax penalty of $695 for those who are unable to secure health insurance - now no longer just an option but a requirement.

Many U.S. tax payers are anxious that the latest health reform will come with a steeper price tag. "I'm anticipating my insurance premium (monthly payments) to increase from $100... to more than $500," fears Terry who works for the federal government and hopes to retire in 2020.

Lesser take-home pay (and savings) combined with the fact that U.S. Medicare coverage in the Philippines is possible (mostly through Medicare Advantage plans) is prompting former Filipinos like Terry to reconsider the Philippines as a good place to get cheap but decent healthcare - yet the "best bang" for dollar earnings.*

Tracy Lim is a freelance writer for My Philippine Retirement. This article has been reprinted with permission from: http://www.myphilippineretirement.com - an information hub that caters to the retirement concerns of foreign nationals and Filipino returnees.

Copyright 2009 myphilippineretirement.com All rights reserved.

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St Joseph's Hospital of Atlanta and United Healthcare of Georgia Negotiating PPO Contracts

St Joseph's Hospital in Atlanta, Georgia and United Healthcare are nearing the deadline for negotiating a new contract. This article will offer an explanation of some of the dynamics behind negotiations between Georgia health insurance companies and medical providers.

In addition to the currently ongoing negotiations between Aetna and Wellstar, there is a problem brewing between St. Joe and UHC. According to the Friday, July 31, 2009 edition of the Atlanta Journal Constitution, a hospital spokesman is quoted as saying UHC had "all but walked away from the table".

Roger Rollman, UHC spokesman, denied the company had pulled back from talks. "We haven't closed any doors," he said. "We've provided St. Joseph's with multiple scenarios of increasing reimbursement and in each instance they'd come back and respond to us that this is what it's got to be. It's a take it or leave it and that's not negotiations." He declined to specify the percentage increase being sought but said it was in the "double digits."

Sources tell me St. Joe wanted 24%.

That's a hefty increase in anyone's book.

So what happens if United HealthCare in Georgia (or any other carrier) caves and agrees to the increase? And what happens to UHC policyholders covered by PPO and HMO plans if negotiations collapse.

If UHC agree's to their demands that means patients who are treated at St. Joe, both currently and in the future, will have to be charged a higher premium to cover the higher costs. Of course UHC has no way of knowing who will need treatment specifically at St. Joe in the future so the cost estimate will be added to total claims and spread out over all UHC insureds in Georgia.

That in itself is not so bad. But what about the domino effect?

If St. Joe get's a big raise, what is to stop Wellstar, Tenet, Piedmont, Northside, Emory and others doing likewise? And why stop in Atlanta? How about the rest of the state?

No one seems to question if hospitals and doctors need more revenue. The only question is, how much is reasonable and then passing it on in the form of higher premiums.

Health insurance premiums rise in direct proportion to the underlying cost of health care. If the cost of health care jumps 24% in one year the premiums must follow.

No one wants that.

What happens to UHC policyholders if negotiations fail?

Not as much as you might imagine, but there will be an impact. Keep in mind that, many times the negotiations go to the 11th hour. Occasionally the contract will be allowed to expire and a new one will be inked within a week or so. Rarely do both parties pick up their bat and ball and go home.

St. Joe is a center of excellence, is ranked in the top 50 of hospitals in the United States, and is the only hospital in Georgia to receive that designation. Many employee's and their dependents who are covered through the Georgia Merit System have their claims adjudicated by UHC, so there is a strong tie between St. Joe and UHC. Some 8500 patients, perhaps many of them Merit System covered participants, are treated by St. Joe and their affiliated clinics.

If this union dissolves, even for just a few days, this does not mean insureds of UHC can no longer receive treatment at St. Joe or their clinics. What is does mean is that St. Joe would be considered a non-par (out of network) facility. As such, claims submitted by St. Joe would be adjudicated and paid at the "going rate" for par providers and the patient would be responsible for the balance.

When a claim is submitted by a par provider, the claim is adjudicated and repriced (discounted) to reflect the agreed upon amount for the procedure. An EOB (explanation of benefits) is generated and provided to the insured and the provider. The EOB lists the procedure, the billed amount, the adjusted amount (reflecting the "discount"), the amount paid by the patient (if any) and the amount paid by the carrier.

Any (adjudicated and approved) remaining balance can legally be collected by the medical provider. Anything excess of that cannot UNLESS the bill is for a procedure that is not allowed under the health insurance policy. An example would be where a doctor order's an MRI as part of a breast examination and the MRI is beyond the scope of what is considered medically necessary under the terms of the health insurance policy.

As a non-par provider, St. Joe would be able to charge patients whatever they wish, over and above the amount offered to other providers for the same procedure, and the patient is obligated to pay that difference. They are no longer protected by a legal contract that limits the amount a provider can charge, and collect, for services rendered.

Other than the possible loss of patients covered by UHC, there really is little incentive to bargain in good faith towards a resolution. If they fail to come to terms with UHC the patient loses and St. Joe can charge (and attempt to collect) whatever the market will bear.

Failing to reach an agreement will really benefit no one. Each party comes away with a black eye (although in most cases like this the public brands the insurance carrier as the bad guy). UHC "loses" a prominent Atlanta hospital. St. Joe "loses" access to at least some future business from UHC insureds.

Of course the patient is caught in the middle of all this and loses more than anyone.

My hope and belief is that there will be a happy ending although the road may be bumpy along the way.

Let Georgia Insurance Shop be your primary resource for information on health insurance and rates in Atlanta and throughout the state. Our Resource page and FAQ section provide valuable information from http://georgiainsuranceshop.com.

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EHR Adoption - New Jersey Experiments With EHR to Cut Physicians' Paper Work

Can billing offices save time and money in insurance payments through EHRs?

Last month, five national health insurance plans along with the two largest plan industry groups announced that they will be launching a groundbreaking initiative in New Jersey to cut insurance paperwork for physicians' offices.

If it's successful, the initiative will be the first experiment in EHR adoption to cut down on chasing insurance money, what providers say is the biggest time and money drain on their practices.

According to a New York Times article about the initiative, the five plans - Aetna, AmeriHealth New Jersey, Cigna, Horizon Blue Cross Blue Shield of New Jersey, and United Healthcare represent about 95 percent of privately insured patients in New Jersey.

The plans are collaborating with two industry groups, America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA), and are using a multi-payer web portal developed by NaviNet, Insurer Connect.

According to AHIP, five physician groups are also collaborating on the project, namely, the Medical Society of New Jersey; New Jersey Academy of Family Physicians; New Jersey Association of Osteopathic Physicians and Surgeons; New Jersey Medical Group Management Association; and Partners in Care, Corp.

The health plans will provide the portal service to 50,000 providers at zero cost, and NaviNet says it will offer them one place where they can, in real-time: check eligibility and benefit information; submit and inquire about claims; and check referral and authorization submissions.

A probable twist in the system is that the individual plans still have to feed the site information, and not all the plans provide the same level of electronic health data, according to the Times. This means that doctors will still be obtaining different levels of individual EHR info from different subsections of the NaviNet portal.

However, provider groups are hopeful. Leaders at the New Jersey Academy of Family Physicians, one of the collaborating physician groups, continue to state their concern that administrative responsibility on physicians grow every year, but they affirm that this initiative is at least a step in the right direction.

A study put out late in 2009 by the Center for Studying Health System Change and referenced on the NJAFP's web site found a gap between policymakers' expectations of and practitioners' experience with EHR. According to the study, what's really required to make EHR work is to reform payment policies to address coordination of care, even within a single providers' office, but certainly among practices.

Provides free weekly newswire of healthcare information and offers advanced Learning Opportunities about EHR adoption for health care IT industry.

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Laser Eye Surgery Costs

All of the fees involved with Laser eye surgery are certainly not an irrelevant number determined on from any surgeons. They are simply determined in accordance to a lot of components, which includes a doctor's working experience, geographic location, and costs. Therefore exactly how much does Lasik amount to, and how much associated with this particular expense is usually taken care of by health insurance?

Generally, individuals may possibly expect to spend five hundred dollars to two thousand five hundred dollars for each eye. Why can Lasik cost that much? Considering it costs hard earned cash to carryout surgical treatment. In eye clinics, the final LASIK eye laser surgery pricing relies upon on just how much the medical expert has needed to work on medical staff charges, anesthesia, non reusable surgery products, laser repair, medical malpractice insurance coverage, and much more. Specialists have got to advertise to lure business, thus marketing and advertising costs are included in as well. Additionally, individuals must be expecting pre-surgery tests and have-surgery check-ups for a year after their own surgery. Their own Laser eye surgery rate include all of these examinations.

Generally there are usually additional things which could double the actual LASIK eye laser surgery cost. For instance, subjects that have intense sight problems could need special Lasik. This possibility constitutes a three dimensional map of the area of this cornea, helping the Rk surgery doctor to offer custom-made re-shaping to get highest result.

People normally wonder if the LASIK eye laser surgery expense changes by country. It will tend to be more over-priced around big towns due to higher living costs connected to these kinds of areas. Your doctor's level of expertise and practical experience will have an effect on the cost of surgery. Clinical professionals that are greatly sought-after will charge much more than their lesser-established counterparts. However, really low prices might point out a fresh medical expert or an assembly-line procedure for Lasik. Select a affordable clinic, but avoid cheaper LASIK at any expense. You do not need to sacrifice your vision for money.

Exactly how much of that Laser surgery fee will be covered by insurance coverage? However, a large number of American insurance coverage firms think of Lasik to remain "not scientifically fundamental". As a result, the surgical procedures are not generally protected by insurance coverage. Some student insurance plans, such as Aetna, are already known to take care of the price of Lasik for university students.

Even though your current plan isn't going to include the procedure, there are still some measures you can take to offset your Eye laser surgery cost. As an example, check if your employer will partner with a eye-sight center to acquire discounted prices with regard to their workers. If your job give you a overall health spending or adaptive spending account, put cash into it month after month for you to utilize it to finance your Laser eye operation. Finally, if you qualify, many Rk surgery laser centers offer their very own financing. A person could obtain the medical procedures with no down payment and deferred interest charges, which makes it less expensive.

Even though the majority US residents need to pay for their own Laser eye surgical treatment, they think the effects are worth the cost. Would you decide to proceed with Lasik, budget one thousand dollars to 5 thousand for both eyes and don't depend upon insurance.

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