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Okay, it is the day after--now what?

2016-11-10 by Colleen King

In a word, NOTHING.  It's November 9th, day after THE election. Sun came up, most birds were still singing, but as far as health insurance and the god awful rates we're looking at for 2017, nothing will change right now.

First of all, Trump doesn't take office until January. When he does I hope he will have been spending a lot of time on building teams to look at many areas, especially health care and how to fix the Unaffordable Care Act. In case he or any of his team catch my blog, I have some opinions of what could help. And no, I don't have the stats to back how much could be saved, or insurance costs could be cut--this is just gut instinct:

  • Modify the 'actuarial values' structure--this is where the law says a Platinum plan has to cover 90% of your costs, Gold covers 80%, Silver covers 70% and Bronze covers 60%. This needs to be modified, especially the Gold and Platinum levels, because these structure are unsustainable. Gold and Platinum plans usually have no deductible. Great, but that makes these plans really expensive.
  • We used to have plans that would offer generic drug coverage only. Government said that wasn't good enough. But what if that's all you wanted, and you were willing to chance it? Shouldn't that be your choice? That would help.
  • Maternity coverage is required on all plans. And to the guys that say 'they' don't need it, 1. you're usually involved when a woman gets pregnant, and 2. I have coverage for prostate exams I don't need. I would like to see it permissible to have a few plans without Maternity coverage, but require carriers to have it on the majority of their plans, like 75-80%--that spreads the cost out, otherwise plans with maternity are ridiculously expensive.
  • Revamp the exchanges--how did they expect to add a whole NEW bureaucratic layer in health insurance administration and bring the cost of insurance down? Shrink the exchange concept down to where they help administer/answer questions about that kind of eligibility. Agents at least in California have been involved in the majority of insurance plan sales on Covered CA. Maybe expand their ability to answer questions about the MediCal side, since it's 'hands off' for them once one is eligible for MediCal and the case goes to the 'Local County Office'--yikes!

That's it for now. I'm sure there's more, like oh, cost containment in the pharmaceutical industry? I'm done....for now....

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But I have a PPO--what do you mean I have a PCP now?

2016-11-02 by Colleen King

One of the main reasons people tend to like PPOs, unless they've had a good HMO experience, is the freedom to choose which doctors they go to. You can see someone contracted with your health plan, or not. If they aren't contracted, you pay more of the cost. And there is no 'discounted,' contracted rate to help contain your costs.

So when Covered CA came out this year and dictated that even if you have a PPO you will be assigned to a primary care provider (PCP) agents were very alarmed, because we knew the phone would start ringing. No, you still have a PPO, you just have a PCP to go with it. Here are the points, good, bad or indifferent, that you need to know about this new thing for 2017:

  • You will automatically be assigned to a PCP. Maybe it's someone you know, maybe not. The carriers are saying they may review claim info to try to assign you to someone that you've been using.
  • You don't have to use that doctor EVER--the theory is, maybe there will be a higher utilization of preventive services if a member has someone to go to, since a lot of people don't have a regular doctor. If you want to change your assigned PCP, just like with an HMO, you can at any time.
  • You can still go to anyone you want, you don't need a referral for a specialist--BIG difference from an HMO PCP.
  • This doctor supposedly is NOT being paid to be your PCP. With HMOs your PCP is paid 'capitation'--$X amount per member, per month, whether they see you or not. So the new PPO PCP, they will be compensated like they are now, when they see a patient.

So, is this going to make a difference, will it increase the use of preventive services? Dunno. Is it going to improve the quality of care? Maybe. Are patients and doctors going to like this? Remains to be seen. Just another change in our health care system that supposedly wasn't going to change once the ACA hit. So stay tuned....

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