FactCheck: Veep debate violations - page 2

FactCheck: Veep debate violations... Read More

  1. Visit  MunoRN profile page
    1
    Quote from Jolie
    And yet those programs are still going broke. Why? Could it be that the issue of overhead is a relatively small one? And that out-of-control costs apply to both privately and publically funded health care? Perhaps capitalism isn't really the main problem. Or even the problem at all.

    Private insurers are now required to refund a portion of premiums if they fail to meet certain benchmarks. Why is the same not required of government plans? Why are we not refunded tax dollars to compensate for fraud and waste when Medicare and Medicaid fail to be proper stewards of taxpayer funds?
    Overhead is by no means a small issue, unless you consider Billions a year to be small. Private insurer overhead runs 14-30%, Medicare overhead runs 2-3%. The overhead benchmark private insurers are expected to reach is to keep their overhead less than 20%, so essentially yes, Medicare is expected to meet this same benchmark (and does so with a large margin).

    The government is required to rid Medicare of fraud and waste. Much of Obamacare is actually aimed at reducing waste, everything from limiting re-admissions to not paying for inadequate care, which then saves or "refunds" the payers of the system. Fraud is not being ignored either; http://www.nytimes.com/2012/10/05/bu...t-91.html?_r=0

    Medicare is going broke because they are responsible for the medical care of a poorly maintained society. By definition, Medicare is responsible for every elderly, disabled, chronically acutely ill citizen, private insurers on the other hand get to hand these patient's over to medicare when they start to actually cost large amounts of money. Even so, Medicare coverage per person is only slightly more than that of private insurers, even though medicare is dealing with exponentially more expensive patients to cover.
    TopazLover likes this.
  2. Visit  Tweety profile page
    1
    Quote from Jolie
    And yet those programs are still going broke. Why? Could it be that the issue of overhead is a relatively small one? And that out-of-control costs apply to both privately and publically funded health care? Perhaps capitalism isn't really the main problem. Or even the problem at all.

    Private insurers are now required to refund a portion of premiums if they fail to meet certain benchmarks. Why is the same not required of government plans? Why are we not refunded tax dollars to compensate for fraud and waste when Medicare and Medicaid fail to be proper stewards of taxpayer funds?
    Lots of issues here.

    Can you clarify "out of control costs"....are you meaning administrative costs or the actual costs of healthcare? I'm not thinking these programs are going broke because of administrative costs only. It's health care costs for a growing number of both people entering the programs for the elderly and the poor, and uninsured on top of higher costs that I feel is the main problem.

    As far as fraud goes, I heard a special on PBS recently about the teams investigating fraud (which are largely done by private citizens or for profit organization like HCA) are how they underfunded to do the job properly and unlikely to get their budget increased to address the problem but they do have some impressive technology out there recovering funds. If your employees or customers steal from you, is that a reflection that you aren't a good steward of your own money?
    Jolie likes this.
  3. Visit  CapeCodMermaid profile page
    0
    I'm more interested in what's going on in my state of Massachusetts. One ballot question would legalize medical marijuana and another would legalize assisted suicide. I'm voting yes to both.
  4. Visit  Jolie profile page
    0
    Quote from Tweety
    Lots of issues here.

    Can you clarify "out of control costs"....are you meaning administrative costs or the actual costs of healthcare? I'm not thinking these programs are going broke because of administrative costs only. It's health care costs for a growing number of both people entering the programs for the elderly and the poor, and uninsured on top of higher costs that I feel is the main problem.

    Federal law now requires insurers to refund a portion of premiums if they spend "too much" on admnistrative costs. While all costs add up, it is my belief that administrative overhead represents a small portion of the excessive increase in the cost of healthcare and subsequently health insurance. I believe this is a "feel good" measure that will do little to moderate, and certainly won't lower the cost of healthcare or insurance. Yet politicians tout this as a major victory for the consumer. I question why federal plans are not subject to the same scrutiny. Medicare and Medicaid tout extremely low overhead as compared to private plans. If we accept that as fact (which I don't, but will here for the sake of argument), then why are they going broke? the answer, in part, is fraud, which is far more ampant in the public sector than the private. My contention is that if private plans must refund for excessive overhead, then public plans should have to do the same for excessive fraud.

    As far as fraud goes, I heard a special on PBS recently about the teams investigating fraud (which are largely done by private citizens or for profit organization like HCA) are how they underfunded to do the job properly and unlikely to get their budget increased to address the problem but they do have some impressive technology out there recovering funds. If your employees or customers steal from you, is that a reflection that you aren't a good steward of your own money?
    To a large extent, yes. All businesses are subject to loss. Some unintentional (such as mis-communications, honest mistakes), some which can be prevented (poor quality work, theft.)

    When we first opened, we were approached by a number of people wanting to sell us loss prevention plans for many aspects of our business. Some focused on employees, some focused on inventory, some on customers, some on security of the building. We chose to take an internal approach and educate ourselves, our managers and our staff on normal operations and what to watch for that might indicate theft or fraud. We have had some losses, including an employee who was stealing from customers, as well as a few that were stealing from us. We've also had some customers attempt to defraud us. We've learned what to watch for, and how to prevent loss, but will probably never be 100% secure, as few businesses are. We have also been very public about the known cases, to make people aware that we will not be an easy mark.

    I think the primary difference between private business and government is personal investment and motivation. Since I don't get paid unless we make a profit, you can bet that I'm a hawk. While most high level managers receive both a salary and bonus, the motivation for manager who does not own the business to detect and stop loss is still great, but not as high as an owner. And sadly, since many government employees are not held accountable for loss, there may be very little motivation for them to detect, report or act on fraud. This is a major drawback of publically funded healthcare and is evident when we read stories about the same provider billing hundreds and thousands of times for the very same services in an unrealistic time frame from some little storefront.
  5. Visit  Jolie profile page
    0
    Quote from MunoRN
    The major cost savings measures don't take effect until January of 2014, so it's not surprising that we didn't really see a change in the rate premiums were increasing in 2009 to 2011, a law doesn't do much when it hasn't gone in to effect yet.
    Then why did Obama make such a lofty claim?
  6. Visit  MunoRN profile page
    0
    Quote from Jolie
    Then why did Obama make such a lofty claim?
    That was the prediction at the time from auditors, although many of the variables involved have changed since then.
  7. Visit  Tweety profile page
    0
    Quote from Jolie
    Then why did Obama make such a lofty claim?
    Because he's a politician and that's what they do. They mean well and they are actually grandiose enough to think they might pull it off. They say what people want to hear...we want to believe they can solve our major problems. They make these claims and hope for the best, but really know it's all B.S. I remember posting here during his campaign for years ago when he was talking about education, that he was blowing smoke up our butts. I could tit for tat about some of Romney's claims too.
    Last edit by Tweety on Oct 14, '12
  8. Visit  Tweety profile page
    0
    Quote from Jolie
    To a large extent, yes. All businesses are subject to loss. Some unintentional (such as mis-communications, honest mistakes), some which can be prevented (poor quality work, theft.)

    When we first opened, we were approached by a number of people wanting to sell us loss prevention plans for many aspects of our business. Some focused on employees, some focused on inventory, some on customers, some on security of the building. We chose to take an internal approach and educate ourselves, our managers and our staff on normal operations and what to watch for that might indicate theft or fraud. We have had some losses, including an employee who was stealing from customers, as well as a few that were stealing from us. We've also had some customers attempt to defraud us. We've learned what to watch for, and how to prevent loss, but will probably never be 100% secure, as few businesses are. We have also been very public about the known cases, to make people aware that we will not be an easy mark.

    I think the primary difference between private business and government is personal investment and motivation. Since I don't get paid unless we make a profit, you can bet that I'm a hawk. While most high level managers receive both a salary and bonus, the motivation for manager who does not own the business to detect and stop loss is still great, but not as high as an owner. And sadly, since many government employees are not held accountable for loss, there may be very little motivation for them to detect, report or act on fraud. This is a major drawback of publically funded healthcare and is evident when we read stories about the same provider billing hundreds and thousands of times for the very same services in an unrealistic time frame from some little storefront.
    Understood and nothing to disagree with.

    However, a lot of the healthcare fraud is not occurring at the government level, it's occurring in private facilities like HCA did in 90's. It's occurring by computer hackers, and what not, so there aren't any government employees motivated or not to report it. Someone approving payment to a "doctor" might not know this doctor is not a doctor and the "patient" died years before. Like I said, it is reported and discovered the resources to combat it are limited.

    I will add to my list of reasons for high healthcare costs government regulation and the Joint Commission. Still other countries have safe outcomes and lowered cost than us.
    Last edit by Tweety on Oct 14, '12
  9. Visit  NRSKarenRN profile page
    2
    People "loosing" Medicare Advantage (MA) plans are really just changing policies back to traditional Medicare or choosing another MA plan due to several reasons:

    a. End Stage Renal disease coverage kicks in after 30month on dialysis -most go back to traditional Medicare. Since MA plans got their additional 10% extra payment cut, all the dialysis companys that had set up MA renal benefit plans "no longer have contracts with Medicare".

    b. Eligibility for dual coverage: Medicare and Medicaid. Some will then change to another MA plan that is specific for dual recepients.

    c. Moved outside MA service territory: MA plans have a restricted US market, they covercertin couties/parishes within each state. So if you have a home in FL, have a stroke and move to PA to live with son, not covered as outside service area. My homecare agency eats the cost of caring for these persons. Traditional Medicare allows you to be treated in every US state without network as long as facility/provider participates; ~95% all hospitals do participate in Medicare.

    d. Lack of in-network providers in new territory that MA plan just expanded too-- so patient that has been seeing same oncologist for past two years, now has huge bill because provider is not in-network with new MA plan; patient was unaware docotrs not in network, chose as cheepest plan --so they switch again to another plan.

    e. Limited income and never paid via payroll deduction so only eligible for Medicare part B, lost medicaid coverage so kicked out of MA program.

    f. MA plan requires PCP approval for services like homecare: PCP refuses to order homecare despite client having need ordered by another specilist like GU/Ortho surgeon cause they want you to use PCP's own homecare agency. Or homecare is limited # visits benefit Client withdrews to get agency services of his choice unlimited under traditional Medicare plan.
    Last edit by NRSKarenRN on Oct 15, '12
    TopazLover and tewdles like this.
  10. Visit  herring_RN profile page
    1
    tewdles likes this.
  11. Visit  NRSKarenRN profile page
    3
    In 2009. after President Obama was elected, a HEAT task force was put together to combat Medicare fraud. Over 1 BILLION/year has been recouped. With passage of ACA/Obama care more monies were put into the effort.

    You can see actions by state here:
    HEAT Task Force News | StopMedicareFraud.gov


    Illinois – March 13, 2012 - Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder discussed how the Affordable Care Act and the Obama administration’s Health Care Fraud Prevention and Enforcement Action Team (HEAT) are helping fight Medicare fraud.- Read More

    Today, the Obama administration also announced more progress from its anti-fraud efforts, beyond the nearly $4.1 billion recovered last year:


    • In the early phase of revalidating the enrollment of providers in Medicare, 234 providers were removed from the program because they were deceased, debarred or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations;
    • In 2011, HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers (PECOS) as it took steps to close vulnerabilities in Medicare;
    • In 2011, HHS saved $208 million through pre-payment edits that stop implausible claims before they are paid;
    • Prosecutions are up: the number of individuals charged with fraud increased from 797 in fiscal year 2008 to 1,430 in fiscal 2011 – nearly a 75 percent increase;
    • In the first few weeks of enhanced site visits required under the ACA screening requirements, HHS found 15 providers and suppliers whose business locations were non-operational and terminated their billing privileges;
    • Through outreach and engagement efforts more than 49,000 complaints of fraud from seniors and people with disabilities reported to 1-800-MEDICARE were referred for further evaluation;
    • A recent re-design of the quarterly Medicare Summary Notices received by Medicare beneficiaries makes it easier to spot and report fraud.
    Having 9,000+ physicians in our home care agency database, we are now running Sanction Checks monthly to check for disbarred/sanctioned physicians. I'm averaging 1-2 physicians every 6 months with criminal activity/failure to pay student loans that are sanctioned thus removed from our active list. Come January my staff will have to reverify all physician licenses as end of 2yr cycle. Add to that the fun of contacting 250 doctors who were removed from Medicare active status in last weeks PECOS database check as they didn't re-enroll this past year, my credentialing clerk and I will be pretty busy this coming week.
    herring_RN, Tweety, and TopazLover like this.
  12. Visit  tewdles profile page
    1
    Quote from Jolie
    If the explosion in healthcare costs is attributable primarily to administrative greed of private insurers, how do you explain the unaffordability of Medicare and Medicaid, which we are told are extremely cost-efficient in their overhead?
    I don't see where in my post I assigned primary responsibility for the "explosion" in health care costs.

    Are you asking about the explosion in the cost of delivering care or the cost in obtaining health insurance?
    herring_RN likes this.
  13. Visit  Jolie profile page
    1
    tewdles,

    I was not trying to assign a meaning to your post, and didn't intend for another poster to take my comments as such. You mentioned the new mandate for insurance companies to partially refund premiums if they fail to keep overhead under a certain percentage.

    "Hopefully we will see these rate increases flatten now that the insurance companies are mandated to cap their "administrative" costs. Only the very out of touch politician cannot see that the average American cannot continue to afford health care that is completely vested in the capitalist market." (Quote from tewdles)

    I was trying to clarify, since your comment seemed to indicate that you believe that limiting administrative costs would dampen rate hikes.

    I don't believe that will happen to any great extent. I realize that everything (overhead, advertising, legal costs, administrative costs, actual cost of care, etc) contributes to insurance rates. I don't mean to imply that cutting back on any of those things is useless, just that that the actual cost of care is by far the greatest factor in the cost of insurance.

    That was the reason for my comparison to Medicare and Medicaid. Despite supposedly low overhead, their costs are exploding as well.

    Not until the cost of healthcare stabilizes will there be any hope of reducing insurance rates. I realize that I have little good to say about Obamacare, but one of my biggest frustrations with it is that it does little, if anything to address the actual cost of care.

    Extending care to additional people is a noble goal, but it will serve to increase costs, based on supply and demand. Adding comprehensive benefits is a noble goal, but it will also increase costs.

    The effective means of reducing costs involve price bidding, competition, opening new markets, all of which are capitalistic concepts that work quite well in keeping our groceries, cell phones and auto insurance affordable and customized to our individual needs.
    Spidey's mom likes this.

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