The state of things to come


If there is any doubt where federal intervention in the design of health benefits will lead, let me present a recent minor example.  The question is not whether the changes are necessarily good or bad, but rather that they add more costs to the already strained health care system.  The fact is we cannot continue to deal with health insurance in this way.  The temptation is great and the rationalization is easy, but there is no way to have “affordable” health care under these circumstances.  Here we are talking about one state, but multiply that by 50 and then consider what 535 members of Congress each with his or her own cause and constituent pressure to please will be able to do. 

On August 13th New Jersey Gov. Jon Corzine signed legislation to make New Jersey the 14th state to require insurers to cover treatments for autism and other developmental disabilities. The law requires health insurance companies to cover the cost of autism treatment deemed medically necessary, including speech and occupational therapy, with an annual cap of $36,000. It also mandates coverage for behavioral therapy, which includes exercises to help autistic children do everyday activities like making a sandwich. 

Under the legislation, A-2238/S-1561, insurance companies will be required to provide  early intervention for all patients with autism, and with other developmental disabilities, who are under 21 years of age. 

Now we are set up for more “medically necessary” debates, but what is most interesting is that the legislation is not limited to children with autism.  Providing speech and occupational therapy for developmental needs has long been a bone of contention.  Some children simply do not develop as quickly as others and have more trouble with speech development than others (which is why in NJ local school boards must provide this treatment once a child reaches age 3).  This legislation, like so many others sets us up for more disputes and more potential abuse regarding medically necessary definitions.  What parent will not want speech and occupational therapy for a child who is behind his or her peers?  What physician will not help build the case for medically necessary?

Gov. Jon Corzine also signed legislation to improve a woman’s access to health insurance coverage for maternity services by ensuring timely reimbursement to health providers. The bill, A-2539 /S-1125, requires health care insurance carriers to reimburse physicians in instalment payments for maternity services provided over the term of a woman’s pregnancy, rather than after the birth of the child. Covered payments will occur on an on-going basis and include office visits, other pre-natal care, as well as the delivery of a baby.

“The stability of our healthcare systems is of utmost concerns to all Americans,” Corzine said at a bill-signing ceremony at the Newark Community Health Center. “This bill that I am signing represents our continued attention toward the delivery of quality health cares services, equally focusing on the patient, and those that provide these vital services.”

“This bill is a strong step forward, and will enhance a woman’s right to choose the best doctors and medical professionals offering prenatal care in New Jersey,” said Sen. Nia H. Gil (D-Essex). “Under the previous reimbursement rules, maternity care specialists would have to provide months and thousands of dollars worth of care to their patients before seeing one penny of reimbursement from the patient’s insurance provider. By switching to instalment payments, we can make sure medical professionals receive payment for services rendered, and expecting moms get the best care they can in the Garden State.”

“Asking medical professionals to go for almost a year without getting paid borders on the absurd,” said Assemblywoman Caridad Rodriguez (D-Hudson). “Allowing them to be paid on an ongoing basis is a much more equitable and fair way to handle maternity services coverage.”

For at least 50 years physicians have been reimbursed at the end of a pregnancy, just as they are at the end of heart surgery.  One could argue that periodic payments are fair, but one could also argue that they will lead to unbundling services and increased cost and they will definitely increase administrative costs for insurers.  This is a cash flow issue plain and simple and has nothing to do with providing quality health care.

What is most interesting is how our politicians are able to ring our bell and equate the payment of a claim, essentially a financial transaction with access to the best doctors, best care and quality health care services. It is this mentality that we should be most concerned about going forward as the federal government becomes more and more involved in determining health care coverage. 

Americans are burdened by the mindset that there should be no limits when it comes to health care and that personal responsibility means only that their insurance should pay for anything and everything.  That’s okay as long as you apply the unlimited part of the equation to the cost as well.

If you plan to attend as town hall meeting, ask just one question, how will any aspects of the proposed legislation lower costs for all participants in the system and manage the rate of increase in the future?

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