‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for--Those words are fairly clear and appropriate . I want to expand on 'fluidity' as a concept to legislative language. Words such as 'unreasonable' or 'reasonable' brings in the judiciary as a partner and will add to the cost of the government. It is my opinion, those words need to be removed and 'actual' figures stipulated. In other words, in defining deductibles a percentage of the cost to a specified percentage limit should be stipulated. And by percentage I mean do the homework and find out exactly what the 'mean' household income is for the USA and stipulate what deductibles are going to be MINIMALLY.
The deductible issue should be clearly stated in a formula to any insurer. That formula would assign a percentage of the Mean American Family Income to health care including cost of the insurance. That formula, written into legislation, should not allow for manipulation and may even benefit some Americans better than others, however, it will be clearly a benefit to the majority of Americans and can be compensated in other ways through increased 'Earned Income Tax Credits' to those families that earn less than the 'mean.'
I mean if the people that care the most about our citizens, namely the Democrats, can't limit the draconian mechanisms of the Republicans, isn't that unethical to the electorate? I believe it is and allows for criticism that should not exist.
Now, to the legislation.
‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;
It means that the items falling under this 'task force' work will be covered. Evidence based means that there is 'sound' reason for a health provider to REQUIRE items for a patient through acceptable ordering procedures now in practice. It limits exploitation of insurance companies to bill for unnecessary items and uphold the dignity of the provider to be sure the citizen has all they need to carry out the 'therapeutics.'
There is absolutely nothing wrong with having a Task Force to set standards and priorities based on current practices that are prudent to a citizen of the country. The real challenge is for the PROFESSIONS to continue to update what indeed is required for their patients to achieve the goal of the therapeutics.' It is up to concerned providers to be sure the Task Force or any other committee making decisions to this effect have complete and current knowledge so 'standards' to insurance providers are appropriate and timely.
Task Forces and Committees is the way the people will speak to the professions and insurance providers. It is the way it is. Citizens need to be involved at this level and I believe there is also Consumer Protections built into all this. Believe me, we have the right President and the right legislature to do this job.
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and
‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.
The government cannot be negligent of its citizens. Standards that apply to immunizations will be honored. There are tried and true methodologies that state what those standards are and there are updates by Health and Human Services to new standards as they are discovered by the professions. This does not place demands on the citizens to comply. It demands the health insurance policies to be sure the coverage is there for those that want it. There will be significant 'evidence' supported provisions in this bill. Evidence means there is research that backs up the need. For any government at any level to demand a private sector comply with established standards there has to be evidence to back up that demand.
‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
There is nothing ambiguous about that. Preventive care for women to be paid by health care insurers will be established by guidelines by Health Resources and Services Administration (click here) that is a part of the Executive Branch under Health and Human Services.
RNs on the rise: Report shows number of nurses continues to climb (click here)
March 22, 2010
That is a good thing as long as they are in practice and not working in other fields that Bachelor prepared nurses can do. It means the cost of health care will come down and that will be reflected by the HRSA reports that can demand changes in the cost to consumers.
‘(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force (click here) regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
Opportunity for Public Comment (click here)
The public comment being taken currently is in regard to renal disease. But, it serves as an example to the access the public has in achieving goals in preventive services. Appropriate health organizations such as National Kidney Foundation (click here) will comment to this agencies to protect citizens and uphold professional standards. I am confident that if the National Kidney Foundation was worried about the standards being set they would seek public opinion is writing to their legislators and otherwise to effect necessary compliance. Citizens have to have faith in organizations that have developed within the democracy to uphold the integrity of the professions and its standards. Everyone cannot be their own advocate, it would take more time than anyone has in a lifetime to do that. Citizens have to be reasonable and trust.Screening for Breast Cancer (click here) |
READ YOUR NEWSPAPERS. That is why there are newspapers !!!!!!!
Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement (click here)
- U.S. Preventive Services Task Force*
| American Cancer Society Guidelines for the Early Detection of Cancer | |
 | |
The American Cancer Society recommends these screening guidelines for most adults.
The people at these Executive Branch agencies are important, but, just as important are the independent agencies such as The American Cancer Society. There are checks and balances within our society and that is a good thing. Being sure the health insurance companies pay for preventive services will bend the cost curve down. Short term financial gains for stockholders aren't the same as long term deficit and debt reduction for the nation.The cost of health care to consumers, not to mention longevity, relies on the 'best practices' to reduce health care costs. That is different than dividends to stockholders and bonuses to CEOs. What is good for the citizen is good for the country.
Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.
‘(b) Interval-
‘(1) IN GENERAL- The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.
‘(2) MINIMUM- The interval described in paragraph (1) shall not be less than 1 year.
‘(c) Value-based Insurance Design- The Secretary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.
March 3, 2010
(Published online 30 January 2007)
doi: 10.1377/hlthaff.26.2.w195
© 2007 by Project HOPE
Value-Based Insurance Design (click here)
Quality, cost (click here)
...Asked for his definition of health care value, Denis Cortese, MD, president and CEO of the Mayo Clinic, sounds exasperated. “It should be clear at this point to nearly everyone, but I suppose it’s not,” says Cortese. “Value is quality relative to cost. Right now plans do not pay for value. They pay for process. That’s a reason value is hard to agree on, hard for some people to define. But the purpose of process should be to improve value, requiring a joint effort between insurers, providers, payers, and patients. It requires new models of care. Primarily it requires knowing outcomes, and acting on that knowledge.”
A form of benefit design that is value oriented, endorsed by Cortese and others, is growing in popularity, especially among employers. Named value-based insurance design (VBID), it promotes the use of services when the clinical benefits exceed the cost and discourages the use of services when the benefits do not justify the cost. There are many proponents, including several payers and some health plan executives. The classic VBID example is lowering — even eliminating — the cost of treatment-related medications for diabetes patients. In fact, a recent study at the University of Michigan did find that lowering copayments does increase compliance.The basic idea is to organize care delivery around medical conditions instead of uncoordinated, sequential visits to multiple providers, physicians, departments, and specialties — the existing and prevalent system that VBID advocates say works against value and increases costs. In the current system, everyone is required to pay the same out-of-pocket amount for health care services. But value depends on patient characteristics, so there is enormous potential for underuse and overuse of resources.
Acceptance of that idea relies on a practical definition of value. Cortese has such a definition: value = (outcomes + safety + service)/(cost + time).
That is a practical equation because:
- Cost and time are easily measurable. “The denominator is cost over a period,” explains Cortese. “You determine the value of a service over time.”...
Congestive Heart Failure. It is a 'symptom' that is treated as a disease. It is a symptom of a weakened heart for whatever reason that occurs, through genetics, heart attack, virus, obesity, diabetes and the list continues.
If a patient is NON-compliant with their medications they will require repeated hospitalizations and it diminishes their quality of life. Congestive Heart Failure is a chronic condition, the benefit of 'compliance' is realized over time after the diagnosis is made. If the medications are 'pivotal' to the best outcomes of treatment regimes/therapeutics then the 'value' is on the medications and how well compliance is achieved. If 'the best value' is for patients to receive uninterrupted medication compliance than it is best to 'fill in the donut hole' in a manner that will be workable for the consumer and those that manufacturer the medication. The 'value' for reimbursement for a physician lies in encouraging 'compliance' through a patient/citizen understanding the importance of taking the medication AS ORDERED. The reimbursement system to the folks involved is based in 'the best value' for the citizen and ultimately for the USA's society.
This requires a great deal of 'judgement' by physicians to 'call the shots' on what exactly is the 'best value' for their patients. It is physician 'top heavy' and requires professional organizations of physicians to be forthcoming in participation to those that will set the standards.
The other aspect is that there has to be 'exceptions' to the rule through dense verifiable medical records that shows any patient that might fall outside the 'compliance' guidelines through no fault of their own, thus, requiring services other than those 'value based.'
I have to run an errand. I'll be back.
