Question: Why large corporations are given a better insurance discount, while small employers struggle to provide coverage at all.
From: Kim W. of Colorado Springs, CO

Answer: This is a very interesting question and before answering, I would like to provide some statistics from the National Coalition on Health. In 2007, $2.3 trillion (or $7600 per person) was spent on healthcare in the U.S. Total healthcare spending equaled 16% of the Gross Domestic Product (GDP). During the same year, employer health insurance premiums increased by 6.1%, or 2 times the rate of inflation. The average annual premium for an employer health plan for a family of four was $12,100 and $4,400 for a single person. For employers with less than 24 employees, the increase was 6.8%. As we all know, employee contribution has continued to climb in an effort to offset the costs to the employer. But the higher the employee contribution, the fewer employees enroll. Various agencies define small employers differently. According to the Agency for Healthcare Research & Quality (AHRQ), ¾ of businesses in the U.S. are considered small employers and they employ nearly 1/3 of the private workforce. AHRQ’s reports indicate that medium to large employers have 50+ employees and small employers have less than 50 employees.

And now as to why smaller employers face higher rates. While larger firms hire Human Resource or Benefits Specialists to manage healthcare issues, the smaller employer relies on the insurance company or a broker to manage and administer. This means more work and cost per enrollee for the insurance company. Smaller firms tend to have higher employee turnover, again more time and cost to the insurance company. The smaller company has an increase likelihood of dropping and then adding coverage and has a higher risk of actually failing. When a company has only a few employees, it is harder to predict the health risks of that employee group and to spread the risk out among employees. To this end, some states even allow insurers to review the medical history of each individual in the group and charge higher premiums for groups that have individuals in poor health.

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According to a recent report from the Commonwealth Fund the number of uninsured young adults (age 19-29) has risen to 13.7 million people in 2006. While this group makes up approximately 17% of the population not eligible for Medicare they account for 30% of the uninsured.

Full report.

Dr. Ruthann Russo discusses the healthcare paradox in the United States and also the individual consumer healthcare paradox.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician, using healthcare quality rating tools, and understanding your medical record. In this episode:

Podcast: The Healthcare Paradox - Dr. Ruthann Russo discusses the healthcare paradox in the United States and also the individual consumer healthcare paradox..

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Question: Is Medicare really all it's hyped up to be?
From: Andrew L. of Cranbury, NJ

Answer: Your question is a broad one. Most people know that Medicare is federally funded and is available at age 65 or younger if disabled and on Social Security Disability for 2 years. What may not be as well known are the types of services covered by Medicare. The following is not an exclusive list of services covered by Medicare but will at least give you an idea of the benefits-inpatient hospitalization, inpatient skilled nursing services, physician coverage, outpatient surgery and therapy coverage, inpatient Hospice benefits, home health services at a skilled level, home Hospice services. Screening tests are also covered. As with any other insurance coverage, there are conditions to be met and limits on the amount of coverage (benefits are renewed if the patient is not an inpatient for at least 60 days). Many patients purchase Medigap insurance to supplement Medicare. Managed Care Medicare plans must provide the basic coverage available in traditional Medicare. More recently, Medicare prescription plans have arisen. Is it all it’s hyped up to be? It appears that the government intended to provide comprehensive coverage for its older and disabled population but also recognizes that ongoing improvements and changes will be necessary.

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Question: Why patients aren't informed as to what their test results, etc. are leading their doctors to believe as a possible diagnosis?
From: Leanne S. of Vineland, NJ

Answer: The federal government guarantees that patients have healthcare rights and providers have responsibilities they must meet in caring for their patients. You have probably seen these Rights and Responsibilities posted in hospitals and clinics that you have visited and have received a copy upon admission to a hospital. One of your rights is to receive information in a clear and understandable fashion and to accept or decline treatment. As a patient, you also have the responsibility to ask questions and share information pertinent to your healthcare issues. These rights and responsibilities apply to tests that have been performed so please ask your physician for an explanation and make sure you understand the results.

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I recently had the chance to speak at the Healthcare Prognosis 2008 hosted by the Main Line Chamber of Commerce at Bryn Mawr Hospital. The event was attended by many local providers and area business leaders and focused on how organizations can improve the healthcare of their employees and how that can actually reduce the cost of health benefits. After the panel, was finished there was a lively discussion regarding personal health planning and how a proactive approach to healthcare can dramatically increase the overall health levels of a community.

In many ways this event may have raised more questions than answers for the attendees. However, it introduced many new ideas to an important group of business and community leaders, which is crucial to effecting real long-term changes.

Question: Is cosmetic surgery covered under normal health insurance?
From: Sherri W. of Milpitas, CA

Answer: Most likely, no. Most medical insurance plans specifically exclude cosmetic surgery. Even dental coverage is limited or reduced for what may be considered cosmetic procedures. I can think of certain situations for which exceptions will probably be made-e.g., a burn patient or mastectomy patient in need of reconstructive surgery or prosthetics. If there is an issue in question, you may need a letter from your physician explaining the necessity of the surgery and that it is not merely for cosmetic reasons. But general cosmetic work such as liposuction, face lifts, tummy tucks, etc. are usually not covered by health insurance

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Question: Why is there not mental health parity across the board with physical health nationally and state-wide?
From: April C-W. of Bradenton, FL

Answer: You are bringing up a point that has no doubt been a point of contention for some time. You are correct in that some health plans cover mental health conditions differently than medical and surgical conditions. I doubt I could satisfactorily explain why that is but action to amend this has started and continues. In 1996, the Mental Health Parity law was passed to provide parity but only for annual and lifetime limits between mental health coverage and medical and surgical coverage. There are hopes to expand parity under this law to include deductibles, co-payments, out-of-pocket expenses, coinsurance, covered hospital days, and covered outpatient visits. Legislatures will most likely continue to amend and clarify this law for many years and the joint committee of the Senate and House of Representatives are also working to eliminate this disparity.

Question: Why do you have to wait to go see the doctor for 1 year if you have a preexisting condition, especially when you are currently paying $200 a month for insurance that you can’t even use?
From: Leslie BB of Rantoul, Il

Answer: A pre-existing condition is any medical condition diagnosed or treated before you join a new health plan. The Health Insurance Portability and Accountability Act (HIPAA) limits a health plan from denying payment for care for a pre-existing condition. Previously, a health plan required a waiting period for pre-existing conditions for new members (e.g., 1 year). Obviously, this could have a detrimental impact on the member’s health and lead to high financial burden for the member. Under HIPAA, if you have been insured for 12 uninterrupted months before joining the new plan, no waiting period is required for the pre-existing condition.

Question:  Where can I find information about Medicare for my grandma?

From:  Garrett B. of Ontario, NY

Answer:  You do not specify what specific Medicare information your grandmother needs.  Medicare is the government sponsored health insurance available to people 65 and older, people who are disabled and have been on Social Security Disability for 2 years, and people with End Stage Renal Disease and have had a kidney transplant or require dialysis.  Part A of Medicare provides coverage for inpatient hospitalization, skilled nursing facility, home care and hospice.  Part B provides coverage for physician services and outpatient care.  To learn more about the specific number of days covered, criteria that must be met to receive the coverage, annual deductibles, etc., you may access several websites and government agencies.  Your local social security office should have information available.  You may want to check into the Department of Health and Human Services website on Medicare by typing www.medicare.gov or www.cms.gov (Centers for Medicare and Medicaid).  Each site provides information on eligibility, covered services (and not covered services) and has many of the Frequently Asked Questions.

The mountain of documentation leading up to the passing of any federal law is evidence of the pain that many, many individuals and groups have endured to get to the final end. While books can be, and have been, written about what can go wrong with passing legislation in a democratic bi-partisan, interest group dominated society like America, much, much more good than bad comes out of this process. The common balance that we seek to achieve in a democracy is one that benefits both society as a whole and individual. This is not an easy feat and usually requires tireless hours of debate and re-framing until a solution is reached. Even then, we have protections against laws that may violate individual rights in the form of our executive branch (the President can veto a law) and the Supreme Court (which can overturn a law as unconstitutional). More importantly, we have the people who elect our legislators as a sounding board for the effectiveness of the laws that are going to be, or have been passed. Strong enough opposition from “we the people” can lead to amendments or even dissolution of laws.

As Complimentary and Alternative Medicine (CAM) is becoming evermore mainstream many states are beginning to license naturopathic doctors (ND). Below is a listing of states that currently license NDs:

1. Alaska
2. Arizona
3. California
4. Connecticut
5. Hawaii
6. Idaho
7. Kansas
8. Maine
9. Montana
10. New Hampshire
11. Oregon
12. Utah
13. Vermont
14. Washington

Dr Russo and attorney Joseph Russo discuss the pharmaceutical industry and prescription drugs and some things you should be aware of when talking with your doctor.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This new podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician , using healthcare quality rating tools, and understanding your medical record. In this episode:

The Pharmaceutical Industry and Prescription Drugs - Dr Russo and attorney Joseph Russo discuss the pharmaceutical industry and prescription drugs and some things you should be aware of when talking with your doctor.

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Medical research is often a controversial topic, however there are many regulations in place to protect patients rights.

Providers must follow specific requirements of informed consent
for research purposes. There is widespread agreement that informed consent for research must contain three basic elements: (1) the physician researcher must provide information to the patient, (2) the patient participant must understand the information, and (3) the patient must voluntarily participate in the study.

In this video attorney Joseph Russo and I discuss this week's cover story for BusinessWeek Magazine, Fresh Pain for the Uninsured.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This new podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician , using healthcare quality rating tools, and understanding your medical record. In this episode:

Pain in the Pocketbook - Dr Russo and attorney Joseph Russo discuss this week's cover story for BusinessWeek Magazine, Fresh Pain for the Uninsured.

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In this video I discuss the notion of informed consent in the healthcare setting, why it is important to your overall healthcare and share an informed consent story from a recent physician visit.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This new podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician , using healthcare quality rating tools, and understanding your medical record. In this episode:

Informed Consent - In this podcast I discuss the notion of informed consent in the healthcare setting, why it is important to your overall healthcare and share an informed consent story from a recent physician visit.

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As mentioned in today's podcast here is the Patients Bill of Rights

The Patients’ Bill of Rights, adopted by the Federal Government in 1996, gives each of us 7 basic rights as patients. These rights are:

While American healthcare is a right only for certain classes of individuals, once you become a patient, regardless of your ability to pay, you do have some guaranteed rights. And, yes, your rights come along with additional responsibilities as well.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This new podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician , using healthcare quality rating tools, and understanding your medical record. In this episode:

Your Rights as a Patient - While American healthcare is a right only for certain classes of individuals, once you become a patient, regardless of your ability to pay, you do have some guaranteed rights. And, yes, your rights come along with additional responsibilities as well.

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The debate over the State Children’s Health Insurance Program(SCHIP) continues to heat up as congress and the president debate endlessly over an appropriate level of funding and how many additional children should be included in the program.

SCHIP, which provides insurance for children of families who make to much to qualify for Medicaid, but can not afford private insurance, currently covers approximately 6.9 million children in the US. Federal funding for the program will expire by the end of this month if a new proposal isn’t agreed upon which may disrupt delivery of healthcare services in several states.

3. Develop a relationship (if possible) with someone at the plan.
Telephone contact is usually available, and if you can develop a relationship with one particular person, it will be easier in the future to get your bills paid. If that doesn’t work, then be sure to get any correspondence with the health plan in writing. Before you call, gather important information such as your insurance card and policy booklet or recent bill. When you receive answers to your questions over the phone, ask the individual to e-mail you the response, and ask for his full name and title. You should document the conversation along with the individual’s name and the date of the call, just in case you followed a directive that is changed in the future. Hospitals use this technique with a fairly good degree of success and you should be able to benefit from it as well.

Good communication is the key to maximizing the benefits of your health insurance plan. . Here is the second of three strategies that will help:

2.When you receive a request from your health plan, respond to it.

Health insurance plans make requests because they lack some information about you. Often this information is necessary to pay a claim. Unanswered requests do not just fade away and they can result in a denied payment or delays that end up costing you money. Sometimes, they can even delay your treatment.

Whenever your health insurance plan requests additional information about a doctor visit or a procedure reply ASAP to ensure you are maximizing your healthcare benefits.

Good communication is the key to maximizing the benefits of your health insurance plan. . Here is the first of three strategies that will help:

1. Make sure you understand the rules of your health plan.

If you have single coverage, understand your plan basics in as much detail as you can. However, if you have family coverage, be sure to select someone to be the health plan expert. Today, most plans have significant resources, most available via the Internet, to explain plan operation and coverage. Your medical mentor may also be able to help. Additionally, many practioners are familiar with the health plans they accept. Sometimes they can offer tips to you about navigating the system. If your insurance is through your employer, your Human Resource Administrator should be able to help you understand your plan or if not, be able to direct you to other resources. Calling your insurance company representative can also help you clarify points of your plan. Whatever resources you use, the more informed you are, the more likely you’ll be able to maximize your benefits.

The Happy Times in Healthcare Podcast is here to help healthcare consumers become better educated in order to receive the best possible healthcare available to them. This new podcast series covers a wide variety of topics including paying for healthcare - when you are insured and when you are not insured, selecting a new physician , using healthcare quality rating tools, and understanding your medical record. In this episode:

What does the healthcare provider charge for their service? - In this edition I discuss how hospital prices are set for insurance companies, government agencies, and uninsured individuals, and suggest how individuals can negotiate a lower medical bill.

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In 1996 the federal government passed the Health Insurance Portability and Accountability Act (HIPAA), which, among other things, provided a mandatory minimum set of privacy protections for patients.

Under HIPAA, health information privacy rights, you have the right to:

1. Inspect and get a copy of your medical records
   
2. Request a correction of inaccurate health information
   
3. Find out where your health information has been shared for purposes other than care, payment, or healthcare operations
   
4. Request special restrictions on the use or disclosure of your health information
   
5. Request that your protected health information be shared with you in a particular way
   
6. See a provider’s policy on confidentiality
   

For the 15 percent or almost 47 million Americans who are not currently insured, there are a myriad of resources that can be tapped. These resources may also be available to you if you have insurance, but you will likely have certain limits or exclusions. And, some of these resources, like participation in clinical trials, are available to anyone who meets the clinical criteria, regardless of ability to pay.

The senate passed legislation Thursday night to expand the State Children’s Health Insurance Program (SCHIP) which provides health insurance to children whose families make to much money to get Medicaid, but can’t afford private insurance.

Under the new bill coverage of US children is expected to increase from 6.6 million to 9.8 million. The estimated cost of this expansion is almost 35 billion dollars to be funded primarily by increases in tobacco taxes.

HRSA is the Health Resources and Services Administration. They are an agency of the Federal Government. The Federal government provides nationwide free-clinic care through the Health Services Resource Administration (http://ask.hrsa.gov/pc/ ). The locations for each of these clinics can be found at the link and most provide Primary Medical, Obstetrical and Gynecological, Dental, Mental Health and Substance Abuse services through the clinics. Many physicians who finish their residencies and have large loans to pay back will work for HRSA Clinics for a period of time and in addition to a salary, the Federal government will pay off all or a large portion of their medical school loan. So, in general, you will receive good quality care from well trained physicians at the HSRA clinics. To meet the Federal government’s definition of a clinic, the facility must meet the following test of physician participation: The medical services of the clinic are provided by a group of three or more physicians practicing medicine together; and a physician is present in the clinic at all times during hours of operation to perform medical services.

Sure, we all inherently believe that healthcare is or should be a right. No matter, in the US, the answer to the question, “is healthcare a right?”, depends on two things: first, who you are and second, whether you have completed the appropriate paperwork. In the US, our government only guarantees healthcare insurance benefits to certain classes of the population, namely the poor and the elderly. So one way to look at expanding the right to healthcare is to determine if more of us can be covered under Federal Government sponsored insurances. Here's who covers what. Medicare covers those who meet one of the following criteria:

1. Over the age of 64
2. On disability
3. Diagnosed with Renal Failure/ESRD and certain other diseases
4. A child of a disabled parent

In addition to economically needed, 35 states have Medicaid programs that provide coverage to additional groups. These are:

1. Pregnant women through a 60 day post-partum period
2. Children under age 18
3. Blind persons
4. Children under age 21 who are full time students
5. Caretaker relatives (relatives/legal guardians who live with and take care of children)
6. Women with breast or cervical cancer
7. Patients with tuberculosis
8. Individuals in need of long term care