Sunday, May 16, 2010

Pass the Bill then DEFINE What's in It

Even the insurance companies are learning that we had to "pass the bill to find out what's in it" and in some cases, even to interpret and define what's in it.  As it turns out, parts of Obamacare are still malleable and, shocker, not clear.

As reported in The New York Times this morning, one of the countless provisions in Obamacare is strict regulation against profits and premiums.  For their part, insurance companies want to be clear what, exactly, that means:

Insurance lobbyists are trying to shape regulations that will define “unreasonable” premium increases and require them to pay rebates to consumers if the companies do not spend enough on patient care.
What is "unreasonable" and who decides?  The Democrats just wanted to pass this thing; they couldn't be worried about defining the rules!  The details can be worked out later!  Pass it then WRITE what's in it.

One [provision] bars insurers from carrying out an “unreasonable premium increase” unless they first submit justifications to federal and state officials. Congress did not say what is unreasonable, leaving that to rule writers.

Here's another one:
Another provision, effective Jan. 1, requires that a minimum percentage of premium dollars be spent on true medical costs related to patient care — not retained by insurers as profit or used to cover administrative expenses. Insurers must refund money to consumers if they do not meet the standards, known as minimum loss ratios.

Michael W. Fedyna, vice president and chief actuary of Aetna, underlined the importance of this issue, saying no other aspect of the law would be so “influential in shaping the future of the health care marketplace in the United States.”

The definition of medical loss ratio will “determine the willingness of health plans to enter new markets and remain in existing markets,” he said. 

I'm not sure where the money for research and development will come in; all those life saving new medicines and new devices.  Experimental techniques.  Research studies.  What exactly are "quality improvement activities" that would be allowed? 

Some consumer advocates, like Carmen L. Balber of Consumer Watchdog, favor a strict, narrow definition of quality improvement activities, limited to those that produce measurable benefits to individual patients.

 Alissa Fox, a senior vice president of the Blue Cross and Blue Shield Association, said that if the definition is too narrow, “health plans will come under enormous pressure to cut back quality improvement activities, including highly effective programs to reduce hospital infection rates.”
The problem is that in the massive Obamacare bill, nobody really knew what they were passing.  The Democrats that voted for Obamacare simply voted for an idea, an ideal, even, a Utopian plan they could conceive but not implement.  

So now it degenerates in to a war of semantics..  Companies are working to reclassify, or rebrand, expenses in order to fall under that "directly to patient care mandate" and to make it appear as if they aren't using secretaries or administrators to run their business.  Horrors!  Making a profit!?  Horrors!  No!  That would be capitalistic!

Meanwhile, emergency rooms are preparing for the onslaught of newly insured who will continue to go to emergency rooms for primary care just like they always have. There aren't enough primary care doctors in America to cover all of them and aren't likely to be now that Obamacare has passed and the new rules for Medicare and Medicare are discouraging them from opening a practice.

The real-world implications in this behemoth are beginning to be sifted out and it's not a pretty picture.

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