Express Scripts

Normally, I’m pretty easy going. It really takes a lot to really get me mad. Express Scripts, Anthem's pharmacy benefit manager, has succeeded royally.

Background: Untreated, I have fairly high cholesterol levels. Over a couple of years my doctor and I have worked out a regimen consisting of 10mg of Zetia and 40mg of Lipitor. Lipitor is a statin, a HMG-CoA reductase inhibitor that blocks the formation of cholesterol in the body. Zetia inhibits the absorption of cholesterol in the small intestine. The mechanisms of action are completely different, but both act to reduce serum cholesterol levels. Anthem approved the Zetia prescription and has been paying for it for roughly five years.

Here’s the situation: When I recently ordered a Zetia refill from Express Scripts, somebody there saw that Zetia required a step-therapy approach…other meds had to be tried and failed (been there, done that) before Anthem would authorize that prescription. Instead of filling the Zetia Rx, like they previously had, they called my doctor and told her that I needed to use something else before the Zetia could be filled. I don’t know who suggested Crestor, but that’s what they replaced it with.

I called Express Scripts. After a very long conversation, they agreed to fill the Zetia prescription. Today, I received a letter in the mail that they also cancelled my Lipitor prescription because Crestor and Lipitor are both statins…something I’d pointed out to the rep on the phone call.

I called them back. Will they reinstate the Lipitor prescription? No. Will they accept a return of the Crestor? No. If I send it back, it will be an unauthorized return and they won’t refund the $50 that they charged my credit card. Of course, I can always get a new prescription for Lipitor and that will supersede the Crestor prescription, but…

So…I’m treating it as unsolicited merchandise under the mail order marketing laws. I didn't order it. I wasn't notified ahead of time about the change. My credit card is on file for drugs that I order, not ones that I didn't. I buy a lot of merchandise on-line, but no reputable vendor sends out merchandise that isn't specifically requested...can you imagine Amazon doing so? I've filed a charge dispute with American Express and they’re taking care of it, but I wonder how many tens of thousands of people have had similar problems.

This seems like a class action lawsuit just waiting to happen. Comments?

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Laudable Carrier Trick (#4 or 5)

Once in a while, carriers do really great things. This is one of those times, and we want to acknowledge it.

First, check out this touching and inspirational story:

"A legally blind 16-year-old runner, Sami is traversing cross-country courses this season with her new guide dog, Chloe, and is believed to be the first high school athlete in her home state of Ohio to compete with an animal."

The teen and her Golden retriever pup run for fun and in competition. But Chloe wasn't free, and Sami's family needed a hand to help her dream become a reality.

And that's where Union Central Life (a division of Ameritas) comes in: Chloe was sponsored as the result of funds raised at Union Central Life (Cincinnati) from casual days. They sell tickets - often $3 each - to dress casually (jeans) as a fundraiser.

Kudos!

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Halloween Tricks

When the ghouls and goblins come around to terrorize you tonight you might want to screen your candy bin for licorice.

If you are going to hand out the gooey black or red chewy candy, you might need to include a warning label.

According to Consumer Reports,

The U.S. Food and Drug Administration warns the tangy-tasting morsel can be tricky if eaten in large amounts by those with high-blood pressure or heart conditions.

FDA food experts say licorice contains a compound called glycyrrhizin, a sweetening chemical that comes from the root of licorice shrubs which are mainly grown in Greece, Turkey and Asia. The glycyrrhizin compound can lower potassium levels, which can lead to abnormal heart rhythms (arrhythmia), high blood pressure, edema (swelling) or even congestive heart failure.

Hopefully the scoundrels at your door do not have heart or BP issues, but their parents may have. We know some of the candy in the beggar's bags is consumed by family members who put their kids up to the annual shake down.

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MassImmigration

If you'd like to see the potential impact that caring for illegal immigrants is likely to have on ObamneyCare©, one has only to look at its progenitor:

"A dogged freshman lawmaker who refused to budge from the House chambers ... until the Patrick administration came clean on how much taxpayers coughed up last year for free health care to illegal aliens finally got his answer..."

Care to guess?

No, higher.

Higher.

Bingo: $93,000,000

According to the Boston Herald, that was spread over 55 thousand illegals, at an average cost of $1,700 per.

Now multiply that over the 58 states and however many additional tens of millions of people, and you begin to get a rough idea about cost.

Now that's a scary (true) story.

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US Health Insurance Costs Rising

Businesses and staff in the US are struggling to meet the increasing cost of health insurance policies, with the cost of yearly family premiums growing at a faster rate than wages.

The country is still dealing with economic issues, however premiums have risen an average of 8% compared to last year which exceeds the wage rise an average employee will have received.

The US system largely relies on employer provision of healthcare but worryingly there is a year on year decrease in the amount of people covered by their employer. Most schemes involve workers contributing towards the policy to allow it to cover their family too, with the average employee contributing 28% of the cost. This is an increase of 131% when compared to 10 years ago.

While no specific reasons have been given for the above inflation increase it has been widely suggested that insurance companies set their premiums in anticipation of the economy improving, which unfortunately has not yet happened.

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Walgreen's commits Seppuku

Last week, we reported on the little tug-o-war between Walgreen's and Express Scripts.

Guess who won?

Yesterday, I received snail-mail from Walgreen's:

"[W}e are not planning to be part of Express Script's pharmacy provider network as of Jan. 1, 2012 ... The following health plans in your area use Express Scripts and cannot ensure continued in-network access to Walgreen's in 2012: Anthem Blue Cross and Blue Shield."

Genius, pure genius!

Take one of the two primary carriers off the Rx table, secure in the knowledge that there aren't a gazillion other pharmacies available to provide what is, in reality, a simple commodity. Given that you can't swing a cat without hitting a CVS, or Walmart or Target (trust me, I've tried), it should take all of, oh, maybe five minutes (max?) to find an alternate distributor.

According to their website, Walgreen's filled "778 million prescriptions in fiscal 2010."

So, they're about to instantly lose over 90,000,000 of those.

Now there's a great business model: voluntarily ditch 11% of your customer base.

Sounds like someone's angling for a bailout...

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Bug, or Feature?

You be the judge:

"[Medicaid], funded jointly by the feds and the states, was devised to cover the poor. But if a provision in [ObamneyCare©] isn't changed that could be the case for people with pretty healthy incomes."

Ooopsie's.

Turns out, even folks in their early 60's making as much as $60,000 a year could be eligible for Medicaid; that's because the bulk of Social Security benefits aren't taxed, so they don't count toward Medicaid eligibility.

When FoIB Holly R tipped me to this article, my response to her was "Um, as far as I can tell, that’s a FEATURE, not a BUG. Remember, the end-game here is single-payer."

'Nuff said?

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Take 2 and skip the Oncologist?

For a while now, folks have been taking low doses of aspirin to lower the risk of heart disease, but who knew that the little pills might be a strong defense against cancer?

Well, some scientists Across the Pond© may have the answer:

"Taking aspirin regularly can cut the long-term risk of cancer ... British researchers found it can reduce the risk by 60 per cent in people with a family history of the disease."

The study, which involved folks from almost a dozen-and-a-half countries, seems to indicate that aspirin can be an effective weapon in the fight to prevent cancer:

"Professor Sir John Burn from Newcastle University, who led the research, said: ‘What we have finally shown is that aspirin has a major preventive effect on cancer but it doesn’t become apparent until years later.’"

In other words, this is a long-term commitment, not an instant panacea. Still, it's an inexpensive way to manage cancer risk, and readily available to the public. The potential downside - increased risk of stomach bleeding and the like - seems to be outweighed by the actual benefits of the regimen.

No final decision yet on the "chewable vs swallow with water" debate.

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You're doing it wrong: Life Insurance and Murder

One of the first things one learns in Insurance 101 is that you're not allowed to profit from illegal acts. So, for instance, you're not going to have a lot of success collecting on your home-owner's insurance if you burn down your house (apocryphal cigars notwithstanding).

And murdering your kids for their life insurance?

Fuggedaboutit!

"A South Carolina mother who told police her son killed three family members and himself has been charged with quadruple murder because she wanted their life insurance money."

Words. Fail.

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Cavalcade of Risk #143: Call for submissions

Julie Ferguson hosts next week's CavRisk, and wants your risk-related post. Entries are due by Monday (the 31st).

NB: We're now using this submission tool: The BC WorkAround

Once there, you'll be asked to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post ("Remarks")

At the bottom of the form, you'll see a drop-down menu; simply select "Cavalcade of Risk" then press "Submit" and you're good to go.

And PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

Thanks!

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Health Wonk Review - Superhero edition now online

HWR co-founder (and all-around mensch) Joe Paduda hosts this week's outstanding round-up of healthcare wonkery.

You won't be disappointed.

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PART II: Courts struggle with Whether Global Warming is “Natural and Probable”

Post by Ross Plyer

Last time, we discussed The AES Corporation v. Steadfast Insurance Company, a recent Virginia case where the growing trend of climate change nuisance cases intersected with the world of insurance coverage law. Critical to the coverage analysis was whether the Plaintiffs in the underlying action, the tiny island village of Kivalina, Alaska, alleged an accident or occurrence, which the Court defined as something that is not the natural or probable consequence of the insured’s actions.

This case centers on the "accident" definition, so let's compare how each state defines it.

• The Virginia definition says an "accident" is a result that is not natural and probable.
• South Carolina defines an "accident" as a result that is unexpected and occurs by chance.

Is it two ways of saying the same thing? How might this case have played out in an Palmetto State court?

In the Virginia case, the court decided the plaintiffs alleged that AES intentionally released greenhouse gas and had good knowledge that those emissions caused global warming.  Thus, global warming was the natural and probable result of their actions, and thus not an accident. A South Carolina court could look at the same actions and find that Kivalina accused AES of emitting greenhouse gas with the knowledge of its effects. Because the result was not unexpected and not occurring by chance, there is no accident. Using a slightly different standard, a South Carolina court could come to the same conclusion.

This back and forth may cause your head to spin, but these are the interesting questions that coverage attorneys like us enjoy wrestling with. The fact that this one centers around a hot-button issue such as global warming makes it that much more interesting.  (To us attorneys that is.)

- Ross

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Death Panels slog on

There has never been any real dispute that ObamneyCare© will, in fact, reduce health care choices. When the power to decide who's treated (and lives) is granted to the state, personal choice goes away. We've seen this under the MVNHS©, and now we're seeing even more evidence that this is the goal of ObamneyCare©:

"MPAC [Medicare Payment Advisory Commission], whose decisions have the force of law, has voted to impose drastic pay cuts on all doctors under Medicare ... The cuts will effectively reduce the real pay for specialists by 50% over the next ten years ... and cut general practitioners' pay by one-third over ten years"

The net effect of these cuts will be, of necessity, a dramatic reduction in the number of primary care docs willing to see Medicare patients, and even fewer specialists willing to treat them. This is often called rationing, but I think it's even worse: it's relegating the most vulnerable among us, those who have "paid their dues" and relied (perhaps unrealistically) on the implied contract that required them to pay Medicare taxes for all those years.

In the longer term, though, this bodes ill for those under 65, as well. For one thing, it demonstrates conclusively that the aforementioned contract is binding only on the citizenry (death, taxes and all that). But consider this: if reimbursement rates are slashed, then physicians' incomes are reduced. So where's the incentive to spend all that time and money in medical school? If there's no realistic path to financial success, then we've explicitly said "my son the doctor? Oh, I hope not!"

Baby, bathwater, some assembly required.

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SOA, ASAP

Got this in email from Anthem, but it is actually pretty industry-standard verbiage.

Which is to say, unfathomable:

"When submitting Anthem Medicare Advantage business, please make sure you are using the correct version of the scope of appointment. The standard template which contains “CMS Approved 09/27/2011” on the bottom of the first page is what you need to use. If this is not used, Anthem will be unable to match the SOA to the application image making it non compliant with CMS. Attached is the correct SOA that you will need to use."

Subtitles, please?

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Border Control

Immigration policy is a hot topic thanks in part to the political landscape, Herman Cain's electric fence and Rick Perry's educate them at taxpayer expense proclamations.

Of course Obamneycrap is also front and center thanks to the upcoming election and pending Supreme Court docket.

So this is a two-fer.

The back story is an illegal immigrant is seriously injured in a workplace accident.

And he does not have health insurance . . .

The University of Texas Medical Branch at Galveston has been treating Francisco Martinez for three months since a workplace injury left him paralyzed from the chest down.

Since Martinez does not have insurance, the hospital is trying to point him back to Mexico, according to his wife. Brandi Cullen Valderram, Martinez’s wife, told KHOU-TV that UTMB has been telling them that there’s no other option but for Martinez to return to Mexico, even offering the illegal immigrant a free flight back, which he doesn’t want to accept.

Doesn't want to go back.

Maybe the health care system in the U.S. is superior to Mexico . . . especially when it is free.

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When is a pill not a pill?

Well, according to Walgreen's, "[o]ur product is not a pill; our product is a health outcome."

How nice for you.

To understand what's happened, let's revisit the Pharmacy Benefits Manager (PBM) model:

"PBM's are (allegedly) a cost-efficient way for carriers to offload the administrative functions of filling prescriptions ... The stated reason for this business model is that it helps carriers to rein in the cost of medications, which make up a disproportionate percentage of claims."

So far, so good, In this case, the PBM is Express Scripts, and their supplier is the friendly neighborhood Walgreen's pharmacist. The latter has decided to enhance its service offering by helping customers manage their own prescriptions. This makes some sense: in theory, the pharmacist knows about the patient's meds and any interaction issues. He (or, of course, she) is often a trusted member of one's health care delivery team.

The problem is that this "enhanced" service isn't free, so Walgreen's is nudging Express Scripts (the PBM) to up their reimbursement rate.

Sound complicated?

It is, but only because we (theoretically) value that extra step on the pharmacist's part. In this case, "Express Scripts' members account for about 90 million of the prescriptions Walgreen fills each year;" that's a lot of pills (and ointments, etc). If the two parties can't reach an agreement, then a lot of current Walgreen's customers will soon be former Walgreen's customers. And it's not like there aren't other options: with a CVS on what seems like every corner, not to mention K-Mart and WalMart and Target all vying for a piece of that rather large (and lucrative) pie, Walgreen's may end up with a rather severe headache.

Is there a pill for that?

[Hat Tip: FoIB Holly R]

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Employer Mandate Under the Radar

And under the gun.

The (Evil) Individual Mandate continues to garner the lion's share of press, but the (also Evil) Employer Mandate is beginning to get some (dis)respect:

"Whereas other suits hinged mostly on a challenge to the law's "individual mandate" ... the Liberty University case also challenged similar requirements on employers to extend coverage to workers."

Currently, employers are under no requirement (other than market forces) to offer group health insurance to employees. Under ObamneyCare©, that all changes: employers will be forced to install ever-more expensive group health plans or face a stiff penalty.

As we've long remarked, this is a no-brainer for employers: given the burdensome new minimum health insurance packages required under ObamneyCare©, any fines (aka taxes) will look like a bargain.

Remember that phrase "if you like your insurance, you can keep your insurance?"

Good times, good times.

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Grand Rounds: Hush! It's the library edition

Dr Jacqueline (PhD) hosts this week's literary-themed edition of Grand Rounds, presenting a beautiful and eclectic collection of interesting medblog posts.

Do check (it) out.

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Romney on ObamneyCare©

Courtesy of the Galen Institute, we have expert analysis explaining just how the President's signature legislation mirrors the Bay State's version:



[Hat Tip: PowerLine]

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Courts struggle with Whether Global Warming is “Natural and Probable” - Part 1

Post by Ross Plyler

Hello! My name is Ross Plyler, and I am based in the Collins & Lacy Greenville office. I'm excited to contribute to our Insurance Practice Group’s blog, and I wanted to take the opportunity to share an interesting case with you.


An environmental case that started in an Alaskan fishing village of less than two square miles and less than 400 residents landed in the Supreme Court of Virginia. That court issued an opinion that could impact the growing trend of climate change litigation.

Here is some background information:



Aerial view of Kivalina, Alaska, USA. View is to the southeast.



Kivalina, an Alaskan barrier island 70 miles north of the Arctic Circle, filed suit in the U.S. District Court for the Northern District of California against numerous defendants, including AES Corporation (a Virginia energy company) alleging their emissions of greenhouse gases caused global warming and warmer winters, which in turn affected levels sea ice leaving their island exposed to erosion. AES tendered the suit to its insurer, Steadfast Insurance Company, and Steadfast filed a declaratory judgment action, The AES Corporation v. Steadfast Insurance Company. Steadfast argued there was no “occurrence” under the policy and thus no coverage or duty to defend the climate change complaint.

In the appeal, the court defines "occurrence" the same as an accident, which is an event that creates an effect that is not the natural or probable consequence of the insured’s actions, and is not intended, designed or reasonably anticipated. The court said the inquiry is whether the Kivalina plaintiffs allege the resulting harm (global warming) is a natural and probable consequence of an intentional act (emitting greenhouse gas).  If so, there is no accident here and thus, no coverage. However, if global warming is an unforeseen or unexpected consequence, then it is an accident or occurrence, and there is coverage.  The court said that because Kivalina alleged that there is “clear scientific consensus” that global warming is a natural and probable consequence of greenhouse gas emissions, then global warming is no accident, and thus not an occurrence, meaning no coverage.

In South Carolina, we don't worry too much about sea ice, but if climate change litigation is a trend, it is interesting to guess how our courts may deal with the issue of whether global warming is a "covered occurrence."  You will have to wait until next time for the exciting conclusion!

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Rationed Health Care

Folks who rely on Medicaid are about to get short-sheeted. With states running out of money (and the federal government running out of folks willing to lend them money) the time has come for Medicaid patients to get well or die.

The taxpayers can't continue funding your health care.

In some states Medicaid patients will max out their hospital coverage in as little as 10 days.

Arizona, which last year stopped covering certain transplants for several months, plans to limit adult Medicaid recipients to 25 days of hospital coverage a year, starting as soon as the end of October.

Hawaii plans to cut Medicaid coverage to 10 days a year in April, the fewest of any state.

Most private insurance plans don't limit hospital stays.

For fiscal 2012, the association estimated state Medicaid spending will rise 19%, largely because of the end of the federal stimulus dollars.

The program served 69 million people last year.

It gets worse.

In January of 2014 an estimated 18,000,000 people will find themselves on Medicaid courtesy of Obamneycrap.

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ACO's: Regulations Cometh

The government came out with its final regulations for ACO’s, or Accountable Care Organizations, all 696 pages of information. As a medical practice manager, my main concern is still “How do I get paid?” The original scheme was a capitation plan, similar to the HMO’s of the 1980’s. In this plan a physician receives a set amount of money to care for the patient, medical care, labs, imaging, etc. If the physician spends less than the insurance company paid him, then the doctor keeps the left-over. If the treatment plan goes over what was paid then the doctor not only is not paid for his treatment, he may owe the insurance carrier. Running the word capitation through the legislation I came across this paragraph.

“Comment: Several comments reflected confusion about the proposed payment model under the Shared Savings Program. For instance, some commenter’s asserted that the program will, in fact, make partial capitation payments, or questioned if providers electing not to participate in the program will continue to receive payment as usual.

Response: We would like to clarify that consistent with section 1899(d)(1)(A)of the Act, fee-for-service providers will continue to receive payments "under the original Medicare fee-for-service program under Parts A and B in the same manner as they would otherwise be made" regardless of whether they participate in the Shared Savings Program. Also, as indicated previously, we do not plan to adopt partial capitation (or other such payment methodologies) at this time, but may do so in the future through appropriate rule-making, depending on lessons learned through demonstrations.”

The reason for ACO’s is to deliver quality healthcare for fewer dollars. It is thought that if the provider is in charge of the money then he will be more judicious on how it is spent. The only problem with this mindset, and why capitation models do not work, is that human beings are not mind readers and all people have different health care needs. A set amount of money per person per year is assuming that the person will not have any life threatening injuries or illnesses. It assumes that diseases that are expensive to treat will not be diagnosed. It assumes that the worst health care issue the individual will encounter is a cold.

Fee for Service plans assumes that each medical patient is unique, that care and treatment will be based on the need of that individual and payments will be made for appropriate services rendered, regardless of cost.

The first paragraph of the 696 page document speaks to new payment methods for Medicare patients. “Value-based purchasing is a concept that links payment directly to the quality of care provided and is a strategy that can help transform the current payment system by rewarding providers for delivering high quality, efficient clinical care.” This is an unneeded process because providers are rewarded right now for delivering high quality, efficient clinical care through the legal system and malpractice suits. If a physician practices poor medicine, then he risks having a malpractice suit brought against him and in some cases, criminal charges. The legal system already has in place safeguards against poor medical practice.

The concept of an ACO is a way to enable the government control over healthcare treatment by pre-setting how much your medical care should cost. In our current system, even with heavy government control, your medical care is still your decision.

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Caution: Falling Prices, er, Benefits

Even big-box mega-retailers are feeling the ObamneyCare© pinch:

"Wal-Mart is substantially rolling back coverage for part-time workers and significantly raising premiums for many full-time staff ... Citing rising costs ... any new employees who average 24 hours to 33 hours a week will no longer be able to include a spouse as part of their health care plan."

What was that phrase we kept hearing?

Oh, yeah:

"If you like your health insurance, you can keep your health insurance."

Gotta love the smell of hope and change.

[Hat Tip: FoIB Jeff M]

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Obamneycare Continues to Take a Toll

As Obamneycare continues an assault on the U S health care finance system another health insurance carrier bites the dust.


American Republic insurance carrier will withdraw from the market.

The move means 110 employees will lose their jobs over the next three years — 40 in Des Moines and 70 in Omaha — and signals the widespread anxiety among insurance companies over the raft of regulation resulting from the health care overhaul bill.

“It’s a fairly predictable consequence of the regulation,” said Michael Abbott, the president and CEO of the American Enterprise Group, American Republic’s parent company, which employs about 330 in metro Des Moines and has its headquarters downtown.

This is at least the second Iowa company to exit some portion of the health insurance market since passage of the health care overhaul in March 2010. Principal Financial Group exited the small group health insurance market later in 2010.

Fewer health insurance carriers means less competition. The result will be higher premiums, not lower as promised by the Obama administration.

How is this Obamneycare working for you?

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Remember: I'll Drink to That!

As we've noted before, a little tipple may be enough to offset the risk of developing dementia. And now, there's even more evidence to support this theory:

"Researchers analyzed 143 studies that looked at the association between moderate alcohol consumption and mental abilities ... most showed that drinking moderate levels of alcohol showed no effect or a decreased risk of dementia and cognitive impairment"

The research stretched back to disco days (1977), and seems to reinforce the idea that, while it's not a good idea to get bombed on a regular basis (which, as it turns out, could actually increase your risk), a reasonable amount on a regular basis could help reduce your risk of these dread conditions.

Salut!

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Healthcare For The Self Employed

Many businesses large and small provide health insurance to their employees, but those who are self employed will need to arrange a policy themselves to cover any unforeseen illnesses.

One of the real advantages of working for someone else is the knowledge that you and your family can be protected through a company health insurance plan, with many people considering this a key component of their benefits package.

As a result it is important for self employed workers to have fast access to high quality healthcare to allow them to return to work as quickly as possible. Most insurers offer coverage to businesses, so it’s advisable to get a small business health insurance quote to ensure you are covered.

Policies will be available that cover just the individual, their spouse and even their immediate family. The cost of the policy will increase depending on the number of people included, so make sure to find something that suits your budget.

Related articles

• Health Insurance for Chronic Conditions (medicalinsuranceinfo.typepad.com)
• Small Businesses Are Overpaying For Health Insurance (medicare8.blogspot.com)

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RomneyCare© Floundering

"After three years of study, the state’s legislative leaders appear close to producing bills that would make Massachusetts the first state — again — to radically revamp the way doctors, hospitals and other health providers are paid." [emphasis added]

Not the brightest lights in the (Boston) harbor, are they?

As we've long noted, one of the biggest problems with RomneyCare© is that increasing the number of insureds means that demand for health care increases. And when demand increases, what did they think was going to happen to prices (given the fact that they're not exactly drowning in doc's)?

The plan that seems to be most likely to be implemented is a variation on the "global billing" model. Now, this has some advantages: for one thing, it seems likely to eliminate the problem of "hidden providers."

It's hoped that this method would essentially "crack the code" of increasing costs.

But will it?

Um, no:

There is no "secret code" to increasing health care costs. There is a finite, limited supply of health care providers and facilities, and they are all in business to make money (or at least not lose too much). When more people have third parties (eg insurers) paying the lion's share of their health care tab, they're going to demand more services. That leads directly to, oh what's that word?

Oh, yeah: rationing.

How do we know that the dim bulbs in Beantown have no clue?

Pretty obvious:

"Those who led the 2006 effort to expand coverage readily acknowledge that they deferred the more daunting task of cost control for another day ... Predictably, the plan did little to slow the growth of health costs that already were among the highest in the nation."

Ooopsies!

In fact, overall health care costs in the Bay State are 15% greater than the national average, while for the past couple of years, health insurance premiums there have risen upwards of 10% a year.

Rock, hard place, some assembly required.

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Humana Exit

The Utah Health Insurance Exchange has lost a player. For one of the few existing exchanges that seems to have a future, losing Humana could be a lone wolf or it could be the start of a domino effect.

Humana’s departure comes at a time of great uncertainty for Utah’s experimental insurance marketplace, which was slow to catch on but posted steady gains in enrollment this year. State officials hope to preserve its unique design while receiving mixed signals from the Obama administration about whether that’s possible.

If Utah is looking to the clueless wonders in DC for guidance they are in worse shape than I thought.

Exchanges are the cornerstone of the president’s signature health overhaul. And though Utah is ahead of the game with one of two operating exchanges nationally, it needs tweaking to meet federal standards.

Participating is expensive for insurers, which have had to handle applications manually. “It creates a work mechanism for us that’s completely different than we have inside the company,” said Regence BlueCross BlueShield regional vice president Jennifer Cannaday at a recent advisory board meeting for the exchange.

The costs are significant, “they are not sustainable,” and they will require a technological fix that currently doesn’t exist, Cannaday said.

Paper applications at an online site?

Are you kidding me?

But “it looks bad” for a carrier to be a leaving, said Sweat, who hopes others don’t follow. Without Regence BlueCross BlueShield and SelectHealth, which own more than 60 percent of the state’s health insurance market, the exchange would cease to function, he said.

Also, Sweat explained that without Humana there are only three carriers pricing policies on the exchange, which could mean higher rates.

Obamneycrap will create fewer options for consumers, not more.

The declared goal of creating more competition and lower pricing is a lie. It will not happen.

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Cavalcade of Risk #142 - Expert edition, now online

Van Mayhall makes his CavRisk debut with an outstanding collection of risk-related posts. Each entry is highlighted and annotated with a deft touch.

Great job, Van, and welcome to the (hosting) club!

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About Insurance Freelance

Professional Indemnity Insurance

When you run your own business, insurance should be as simple as possible.

In addition to providing quality coverage of a few pounds a day, we strive to provide fast and hassle-free, which provides coverage and can easily be arranged online.

Our system provides Real-Time Underwriting rate, quote, bind and buy a policy in an easy 5-minute transaction. You can also print your proof of insurance.

For more information Please visit: PI Insurance

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Methamphetamines vs. Narcotics - What do they mean anyway?

 

Post by Lee Floyd

Hello all!

I'm Lee Floyd, a self-admitted sports junkie who practices law at the Collins & Lacy Columbia office. When I'm not wake boarding or playing golf in my spare time, I'm enjoying the company of my wife, Kelli, and our two dogs, Fenway and Dustin.  I've been with the firm about four years practicing primarily insurance coverage, professional negligence and products liability law. I love what I do, and now I get to share it with you through this blog. So here's my first post. I hope you like it, and I look forward to your suggestions for more. - Lee.

Methamphetamines vs. Narcotics - What do they mean anyway? The ordinary and usual meaning rule cuts in favor of the insurer in Hutchinson v. Liberty Life Insurance Co.


The South Carolina Court of Appeals recently reversed an order granting summary judgment to an insured under an accidental-death insurance policy, holding methamphetamine fell within the ordinary and usual meaning of the undefined term “narcotic.” Hutchinson v. Liberty Life Insurance Co., 393 S.C. 19, 709 S.E.2d 130 (Ct. App. 2011).

Here's what happened.

The accidental death insurance policy excluded coverage for injury resulting from an insured being “under the influence of any narcotic.” The policy did not define “narcotic.” The insured died two days after the policy became effective when he drove a tractor-trailer off an interstate highway. The death certificate cited the cause of death as blunt force trauma but also listed methamphetamine use as another significant condition contributing to the insured’s death. Liberty Life denied the claim under the policy citing the illegal drug use exclusion. The insured’s beneficiary brought a declaratory judgment action seeking coverage and for bad faith and violation of the South Carolina Unfair Trade Practices Act.

In the original ruling, the Circuit Court held the term narcotic did not include methamphetamine because the drug is a stimulant rather than a depressant and did not fall within the insured’s expert testimony that the scientific definition of narcotic drugs only includes drugs that “induce pain relief, drowsiness, sleep and similar states of stupor.”

The Court of Appeals reversed, holding the Circuit Court erred in applying the scientific definition of the term narcotic rather than a definition using the usual understanding of the term narcotic to the ordinary person. The Court then cited cases using the terms narcotic and methamphetamine interchangeably and quoted the reasoning that the term narcotic ‘“has come to have a generic meaning for drugs considered to be illegal.’” Id. at 25, 709 S.E.2d at 134 (quoting Doe v. Gen. Am. Life Ins. Co., 815 F. Supp. 1281, 1285 (E.D. Mo.1993)).

Main Takeaway: In applying this generic definition, the Court held a layperson would commonly understand methamphetamine to be a narcotic drug based on its widespread illegal use.

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Qualifying for Medigap

Applying for Medigap in Georgia? If you are not "guaranteed issue" as defined by Medicare you will be required to answer a few health questions. Every Medigap carrier is different but most use a 5 year look back and want to know if any of the following are true.

In the last 5 years have you been diagnosed with, or treated for any of the following medical conditions?

Alzeheimers, dementia or Parkinsons?

Heart attack, pacemaker installed, heart valve replacement, stents, irregular heart beat, COPD, or stroke?

Asthma, emphysema, use of oxygen, inhalers or nebulizers

Internal cancer, leukemia, Hodgkins, or melanoma?

Insulin dependent diabetes, AIDS, ARC, kidney disease or renal failure?

Are you cofnined to a wheelchair or do you need a cane or walker for normal daily activities?

Are you confined to a nursing home or have you been hospitalized more than twice in the last 2 years?

If you answer "yes" to any of these questions you will not be offered a Medigap plan unless you are subject to a Medicare approved guaranteed issue enrollment period.

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MVNHS©: Deadly for Seniors

Speaking of Death Panels:

"Elderly patients are being condemned to an early death by hospitals making secret use of "do not resuscitate" orders"

Here in the 'States, Do Not Resuscitate (DNR) orders are "affirmative;" that is, one must pro-actively sign a special form indicating that this is indeed one's desire. Absent such permission, it's generally difficult to legally force a health care provider to withhold or end treatment (cf: Terri Schiavo).

Not so in Merry Olde England:

"The orders ... are routinely being applied without the knowledge of the patient or their relatives ... At another hospital, junior doctors freely admitted that the forms were filled out by medical teams without the involvement of patients or relatives."

How's that "first, do no harm" thing working out for the Much Vaunted National Health Service©?

And it's widespread, as well:

"The findings emerged in spot checks of 100 hospitals ... A charity for the elderly said the disclosures were evidence of "euthanasia by the backdoor"

Of course, it's an easy "fix:" dead grandma's don't have much to say or about which to complain. And talk about savings: cutting off medical care is a sure-fire way to meet funding quotas, especially when end-of-life care has become so expensive. Here, of course, we simply lop off a half trillion dollars from Medicare to fund a major health care overhaul (to the immediate benefit of Junior Americans).

Which begs the question: are American seniors safe?

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Grand Rounds (with a hint of Garam Masala)

Dr Sumer Sethi hosts this week's tasty collection of interesting medblog posts, sprinkled with beautiful photography.

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Anatomy CLASS

Now that HHS Secretary Shecantbeserious has subjected the CLASS Act to a very real Death Panel, a postmortem is appropriate.

Let's note first that we called this some time ago (not that this was any great feat of prognostication). The fact is, this program was never fiscally sound or sustainable in the first place. Then, too, Long Term Care insurance is one of the two most complicated products in the life/health marketplace, which made it a less-than-ideal candidate for any type of government-run plan.

There's a larger, more immediate issue, though: the "savings" anticipated by the CLASS program were among those counted on to help fund the rest of ObamneyCare©, and those (alleged) savings are now gone in a puff of smoke. This leaves the rest of the initiative struggling even harder with regard to funding, even as we begin the last laps towards full implementation.

Finally, it's fascinating to me that a cornerstone of the President's signature legislation has just been deleted by fiat, courtesy of his own agency. No vote, no public discussion or disclosure, just...gone.

How's that for transparency?

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Remember, "The Andromeda Strain" was only a novel

The New York Times reports that scientists researching the Black Death have solved its genetic code and hope to recreate the microbe itself.

Good luck with that.

Seriously.

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For the record: ObamneyCare©

Regular readers may be puzzling over the lack of coverage here regarding the "news" that various RomneyCare designers were brought in by the White House to advise the Obamastration on implementing its signature legislation.

Here's why:

D'unh.

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Cavalcade of Risk #142: Call for submissions

Van Mayhall makes his CavRisk hosting debut next week. Entries are due by Monday (the 17th).

NB: We're now using this submission tool: The BC WorkAround

Once there, you'll be asked to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post ("Remarks")

At the bottom of the form, you'll see a drop-down menu; simply select "Cavalcade of Risk" then press "Submit" and you're good to go.

And PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

Thanks!

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Obamacare White Person Tax Falls Short

Funding Obamneycrap would come from many sources, including a tax on white people. The tanning bed tax was estimated to bring in $200 million per year.

The first 9 months of 2011 has generated only $54 million which means the expected revenue will be less than half what was expected.

I guess white folks (other than John Boehner) are learning to like their natural skin color.

This is par for the course given all the other projections used to sell Obamneycrap to the public.

All the promises of premiums dropping and no more "discrimination" of children have failed to meet the expectations.

Why should this be any different?

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