Obamacare Allows Appeals to the Insurer and, If Necessary, to a Third-Party Reviewer

A Kaiser Health news story noted “Federal rules ensure that none of the millions of people who signed up for Obamacare can be denied insurance — but there is no guarantee that all health services will be covered.”

“A 2011 GAO report sampling data from a handful of states before the health law took effect found that patients were successful 39 to 59 percent of the time when they appealed directly to the insurer. When appealing to a third party (such as the state insurance commissioner), patients also were often successful in getting the service in question – winning as many as 54 percent of such decisions in Maryland, for example. ”

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“We Called It a Hotel near a Major Teaching Hospital”

“Though the views were spectacular, the cardiac arrest team could not get there as quickly as it could to the regular wards.”

The New York Times article asked the questions “What is going on here? Is This a Hospital or a Hotel?”

“The Henry Ford health system in Michigan caused a stir after it hired a hotel industry executive, Gerard van Grinsven of the Ritz-Carlton Group, in 2006 to run its new hospital, Henry Ford West Bloomfield. There are some medical arguments for the trend — private rooms, for example, could lower infection rates and allow patients more rest as they heal. But the main reason for the largess is marketing.”

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“Medical Errors Are a Quiet and Largely Unseen Tragedy.”

“Every year between 210,000 and 440,000 Americans die as a result of medical errors and other preventable harm at hospitals, according to researchers.”

These numbers are equivalent to a jumbo jet crashing every day with no survivors. Based on these figures, medical errors could be considered the third-leading cause of death in America, behind heart disease (more than 590,000 a year) and cancer (more than 570,000 a year).

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“Many People Will Not Be Able to See the Physicians Who Have Treated Them for Years, Use Facilities Providing the Most Appropriate Treatment, or Access Care within a Reasonable Time and Distance from Their Homes.”

Don’t assume that you can continue to see your doctor…

A City Journal article noted that “… having health insurance is not the same thing as getting good health care, or any health care. In fact, it doesn’t matter how many Americans obtain insurance under the ACA. Most will have difficulty finding a physician.”

“Those who do get coverage through the exchanges and pay their premiums will also struggle to get medical care. The ACA requires insurers to accept every patient regardless of risk, provide expansive benefits packages, and eliminate caps on lifetime benefits. Looking to control costs, most insurers are offering exchange plans that severely limit the number of doctors and hospitals patients can visit. Some state exchanges—including New York’s—don’t offer a single plan that covers visits to out-of-network doctors or hospitals.”

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“In Fact, It Doesn’t Matter How Many Americans Obtain Insurance under the ACA. Most Will Have Difficulty Finding a Physician.”

The City Journal article noted ”… having health insurance is not the same thing as getting good health care, or any health care. Many Americans could lose their employer-provided insurance if firms decide that paying the ACA penalty—and maybe giving small raises to their employees—is cheaper than offering health insurance as a benefit of employment or reduce workers’ hours (the ACA does not mandate coverage for part-time employees).”

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Chronic Disease Management Is Not “Free” Under Obamacare

Here’s a Q&A from Kaiser Health News:

“Q. My doctor added on a charge for a “chronic disease management” appointment on top of my annual physical because I have thyroid disease and arthritis. The doctor’s office explained that my visit was more complicated than a routine physical. I’m not sure I buy that. In my case, it only cost a $20 copay, but I was surprised that it was billed that way, and it could be a surprise for someone without the excellent coverage that I have. Can they do that? ”

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“A Visit To The Doctor May Mean Seeing Someone Else Instead.”

New models of clinical practice are being used in the “doctor’s office.”

A Wall Street Journal article noted: “An increasing number of practices are scrapping the traditional one-on-one doctor-patient relationship. Instead, patients are receiving care from a group of health professionals who divide up responsibilities that once would have largely been handled by the doctor in charge. While the supervising doctor still directly oversees patient care, other medical professionals—nurse practitioners, physician assistants and clinical pharmacists—are performing more functions. These include adjusting medication dosage, ensuring that patients receive tests and helping them to manage chronic diseases.”

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