Balancing Billing & Health CarING

TRI-PAC Health and Wellness Advocacy known for its health consumer advocacy is pleased to announce an important legislative victory for all Californians.

A California Judge upheld state recently enacted rules banning the practice of balance billing for emergency medical care.

Rules forbid providers from balance billing patients by making it an unfair billing practice; allowing State Department of Managed Care to pursue enforcement action against providers.

Both the CMA, the California Hospital Association and the Hospital Association of Southern California argued that the California Department of Managed Care, issuer of the ruling, exceeded its authority to issue and enforce the regulations.

The editorial board of Sacramento Bee also says Californians won a major health care victory on Wednesday. "Now, patients who end up in an emergency room cannot be billed for services that are covered by their health insurance -- care they already paid for through insurance premiums, deductibles and co-pays.”

While the CMA, supported by the hospitals, is trying to appeal the ruling we are appealing to the CMA and the hospitals to refrain from their unfair medical billing practices effective immediately.

We advocate; Hospitals, Physicians, and Other Provider Groups Obfuscate, Litigate, and Castigate; You decide!

Hospital Association of Southern California (HASC) has "a Lot" to hide.

No way to know if hospitals are prepared for disaster!?

Nov. 13, 2008, CHICAGO – The findings of a new study published today in the American Medical Association’s (AMA) Disaster Medicine and Public Health Preparedness journal found that consistent, evidence-based performance measurements are needed to accurately evaluate hospitals’ ability to manage patient care during a disaster.

The study has been released early on the AMA disaster journal Web site and will be published in the journal’s December issue: “Although health care institutions regularly perform quality assessments of routine clinical services, few metrics are available to evaluate the quality of their emergency management initiatives,”

“The need for universally accepted,evidence-based performance measures continues to grow, as hospitals must be able to demonstrate their progress or needs for disaster readiness.”

Health care institutions have invested considerable resources in emergency management preparedness, but because major disasters are rare, they continue to be challenged in evaluating the strengths and weaknesses of their emergency programs.

Evidence-based preparedness policies are needed that model current health care quality improvement programs. One way to create such models is to evaluate hospital procedures during times that approach disaster levels.

Traditional hospital quality measures, like wait times and missed diagnoses, can be applied, and the results can be compared to peer hospitals to determine strengths and weaknesses.“It is important that performance standards be established for times of disaster to ensure uniformity across institutions systems, and regions...Ultimately, hospital emergency management strategies are essential to our nation’s preparedness.”

Upon receipt of the pre-publication copy of the report we have forwarded a copy to Mr. James Lott, EVP for Policy Development and Communications for the HASC and requested his comment on the issue, specifically regarding evidence-based performance measures either currently used and/or to be implemented by his member hospitals.

To our shock and surprise the written reply received form Mr. Lot was an angry personal one and did not address the issue: " ...we at HASC are reserved about responding to communications and queries from you."

Unfortunately, we can not separate Mr. Lot an HASC dislike for our Organization, its Leadership, Mission and Values, from the fact that members of the HASC, and HASC itself, are ill-prepared and ignorant while potentially jeopardising the lives and well being of patients, first responders, staff and visitors at their facilities!?

For questions regarding Emergency Preparedness of a particular Hospital in Southern California please call Mr. Lot at (213) 538-0777.

We advocate, you decide!

Long, long overdue!

Reported by Robert A. Donin, MPA, President.

After four years, North Coast state Assemblywoman Patty Berg late Tuesday earned thegovernor’s signature on a bill that requires doctors to tell terminally illpatients about their options at the end-of-life.

“It’s a wonderful day,” said Berg. “I’m so pleased that we were finallyable to do something to address the rights of dying people.”Assembly Bill 2747 succeeded where Berg’s other attempts had failed.

The bill says that a patient who learns they are dying of a terminal disease has theright to ask and be told about all the end-of-life options available to them —from pain-management to hospice care.

A recent nationwide study by cancer doctors found that only one in three terminallyill patients were told about their treatment and pain-management options by theirdoctors.

Those patients who did receive information were less likely to die in intensive careand more likely to receive hospice care.

Among supporters of the bill are TRI-PAC Health and Wellness Advocacy, the Medical Association; the CaliforniaPsychological Association; California Nurses Association; California Commission onAging; AIDS Project Los Angeles; Conference of California Seniors.

Mental Health Parity, or NOT!?

By Robert Donin, MPA, President, TRI-PAC Health and Wellness Advocacy
http://www.2saveyou.com: email: robertdonin@yahoo.com

A new law requiring employers to provide mental health insurance benefits comparable to their medical coverage, mental health “parity” was tacked on to the financial bailout package signed into law by the President on October 3, 2008

It will provide parity in insurance benefits for an estimated 113 million Americans. Employers with 50 workers or less are exempted.

The new law would ban insurance plans from selling higher deductible or copayments for mental health or substance abuse treatment than for medical care. Lower benefit levels would be illegal as would caps on the number of outpatient therapy sessions or inpatient treatment days.

An earlier House version of the bill had required employer plans to cover every disorder diagnosis listed in the American Psychiatric Association (APA) Diagnosis Statistical Method (DSM), the “bible” for diagnosis and treatment. That bill version was opposed by insurers, employers, and the Bush White House.

Insurance premiums may increase as the legislation becomes effective.

The law would provide needed options for some by covering out of network mental health care if people can go out of network for medical treatment.

TRI-PAC congratulates and commends the original author Senator Paul Wellstone (D-Minnesota) now deceased, killed in a plane crash. He had a brother who was mentally ill. Senator Pete Domenici (R-New Mexico), has a daughter with schizophrenia.

From the House of Representatives, Rep. Patrick Kennedy,( D-Rhode Island) treated for depression and by his own account “the public face of addiction and alcoholism” after a car crash on Capitol Hill in 2006 and Rep. Jim Ramstad, (R-Minnesota) when in 1981 he woke up in a jail cell in South Dakota after an alcoholic blackout.

It took 12 years for mental health parity legislation to pass and become a reality.

How does one measure let alone determine conditions of success for mental health parity, how will our people be impacted?

More later.

From Mangled Care to Direct Health CarING©.

The process of health carING© is almost insurmountable in its multifaceted complexity, thus according to the rules of non-linear dynamics it simply can not be “managed”.

What can be managed, meaning rationed, are the ever-rising costs of such carING©.“

Managed care” is a primary oxymoron by default; in its present form is best described as mangled care.

When originally introduced to our naive country and promoted by then ,and still, misguided and ill qualified Mrs. Clinton and her Jackson Hole Task Force, mangled care was, defined as:

" A prepaid risk-based system of integrated health care delivery, having appropriate capabilities to improve quality of care and manage utilization and cost of a given population.” (Thomas Morrow, MD., at NMHCC/IT Fall 1998, Los Angeles, CA)

These for-profit extremely profitable mangled care companies have embraced, and function under divergent and practically mutually exclusive core values.

On one hand, these companies are obligated to provide rather than ration health care services.

On the other, their entire existence hinges on their obligation and ability to generate consistent profits for their executives and shareholders.

More often than not, provision of appropriate health carING© and profit margins of mangled care companies come into direct conflict.

This conflict fuels a “double explosion” of the system: while availability and quality of health services goes down; costs of services to purchasers and profits of mangled care companies go up.

This abominable situation creates significant financial “counter-incentives” to provision of appropriate, accessible, affordable health carING© which can be gauged by the divergence coefficient.

Such counter-incentives further negatively effect already financially squeezed powerless and frequently frustrated health providers.

In addition to divergent and conflicting core values, double explosion, financial counter-incentives and overall patient and provider frustration there is, what I coined, business disconnect.

Entire purpose for insurance, companies, HMOs and other "mangled" health care organizations existence is to grab as many pennies from consumer’s health care dollar as they are allowed to by the workers.

Business disconnects exist due to interlined logistical, financial, physical and ethical aspects of mangled health care:

•The recipient usually does not request, does not order, or pay for the service.

•The payor never requests, does not receive, nor order the service.

•The orderer does not pay, nor receive the service.

In order to achieve their business objectives, here are some of the strategies used:

•If someone is already paying a lot, let him or her continue.

•Even if a lot of people complain about managed care quality, it won’t contain cost.

•Never provide coverage unless the treatment is unpleasant.

•Quality is being in a waiting room with people who earn more money than you do.

Please visit www.workingamerica.org/healthcarehustle maintained by AFL-CIO for real life stories.

Despite such an unorthodox business model, they do grab a sizable chunk: 17 cents out of every healthcare dollar without actually working, being sick, or providing services.

Here are three of many “secrets” in health carING © that health insurance companies do not want health consumers to know:

• Health consumers can request and receive health carING© from doctors, nurses, pharmacists, hospitals, labs, pharmaceutical companies, and others without mangled care.

• Doctors, nurses, pharmacists, hospitals, labs, pharmaceutical companies, and others can provide health carING© without mangled care.

• Healthcare consumers can pay for health carING© without mangled care companies.

Only complete elimination of mangled care as the middle man, can generate enough money to provide appropriate, accessible and affordable health carING©.

Patient-driven health care model promoted by mangled care must give way to direct health consumer-administered health carING ©.

We gripe, you decide!

TRI-PAC

Patient-Provider Partnerships for Appropriate, Affordable and Accessible Health CarING (TRI-PAC) was founded in 1993 by

Prof. Victor S. Dorodny, M.D., Ph.D., MPH. to protect and expand patient rights in a "mangled" care environment.

TRI-PAC Health and Wellness Advocacy , operated by Robert A. Donin, MPA, is nationally recognized non-profit, well known and respected for obtaining the best possible results for its clients.

Since it’s inception TRI-PAC continues to assist both patients and conscientious providers to deliver best appropriate care vis-a-vis HMO bureaucrats and stockholders; and powerless and/or financially counter-incentivised physicians.

Over the past 15 years we were fortunate to be able to assist hundreds of patients coping with life changing illnesses with such issues as denial of care, appropriateness of care, access to care, limits of coverage, out-of-network services, to name a few.

Governed by a respected Industry Advisory Board, TRI-PAC has been extremely effective working with local, state and national legislators and regulators to influence policy and politics of health care, as well as the practical aspects of delivery of health services.

We are proud to successfully defend the health consumers rights of our members/clients in their fights with the likes of Kaiser Permanente, Humana, Blue Shield, Health Net and others, whose bad faith actions and inaction's were jeopardizing patent's lives and well being.

For more information on our organization, membership, etc., please contact Mr. Robert A. Donin, M.P.A. by mail: 11693 San Vicente, Suite 346, Los Angeles, CA 90049, (310) 420-2169, or by e-mail: robertdonin@yahoo.com

Founder & Chairperson of Board, Victor S. Dorodny, M.D., PhD, MPH can be reached by e-mail at Dorodny@medscape.com

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