Here is a list of common mistakes that people make all the time when choosing a health care plan. They are in no particular order, and all are important to consider, carefully and completely. If you are not conversant with all the terminology or are finding it difficult to make the decisions, you should ask for help from a neutral third-party such as family member or friend. Don’t ask a health insurance company unless you want to hear a sales pitch!

Common mistakes
- You don’t check out your doctor, or any others – Although some healthcare plans require you to use a physician in their own network, other plans are more inviting. If you already have a physician, and are buying your own insurance, check with the doctor to see what plans he is a member of. If you do have to choose a new doctor, you should look into the health plan doctors’ credentials by contacting the AMA.

- You forget “location, location, location” – The location of your doctor or clinic, and the travel time required, are other factors you should consider when considering health care plans. Find out where the doctor is located and also look into the regular and emergency hours of the facility.

- You don’t consider specialists – If you already need specialist care, or think you may need to in the future, you need to know the health care plan’s procedures on using them. Some plans require you to contact a primary care physician, while others allow you to make specialist appointments directly.

- You don’t consider your own specialist – You should definitely find out if your current specialist is in the health care plan you are considering. If not, perhaps your specialist can refer you to one who is.

- You forget to check the policy on “pre-existing conditions” – Even though this should be a “no-brainer,” people forget to ask about the policies on pre-existing conditions. Coverage for pre-existing conditions varies widely among health plans. Some exclude them entirely, and will not even consider coverage, while others cover them fully. Many health care plans fall somewhere in the middle, offering coverage after a certain amount of time, or for a certain amount of time or expense. Rules promulgated by the Health Insurance Portability and Accountability Act guarantees you coverage for your pre-existing conditions if you join a new group plan offered by your employer after being insured the previous year. Do your research to make sure you know what your policy covers.

Less common oversights
- You don’t ask about physicals and health screenings – Again, it seems an obvious thing to ask, but if you appreciate getting regular physicals and health screenings you should ensure that they are covered. Most “managed care” plans do cover these types of procedures, usually on an annual basis, but there are some plans that do not cover them. If you have children, make sure to ask if “well baby” check-ups, physicals and immunizations are covered.

- You forget about additional services – Everything, from prescription drug coverage to mental health care, is an important consideration. You need to consider which of the various additional services that you may need are, in fact, covered when you are comparing health care plans. Other examples of these additional services that may be important to you are drug and alcohol counseling and treatment, home health care, nursing home or extended care, hospices, experimental treatments, alternative and complementary medicine, chiropractic care and physical therapy.

Bottom line considerations
- You don’t price things out correctly – Once you know what you want in your health care plan you need to compare costs, and you need to do it right, which means covering all the bases. You will need to know exactly what deductibles must be paid first before the health care plan coverage starts paying, and don’t forget to ask if the deductible needs to be met before certain services can be utilized. Find out about “out of network” charges if you anticipate having to go beyond your plan facilities or physicians. Finally, there are co-payment, cap amounts and total-care limits you need to know about. Some plans have lifetime limits, some have lifetime and annual limits, and others have mixed formulas for making this determination. Get all the facts.

- You don’t check the exclusions – If you don’t read the exclusions list, you will not know what is not covered. You need to see if any condition you currently have, or that you expect to contract in the future, is included. This is an important bottom-line consideration since, if you don’t get this settled and dealt with up front, you will likely spend a great deal of money down the line to treat excluded conditions.

It is a difficult thing to look at your health in a dispassionate, dollar-oriented way, but that’s life. As we age, more of our energy goes into thinking and planning against death and disability, but the subject need not be morbid or depressing. Do your best to get a health care plan that covers what your particular needs are, and remind yourself that you are worth the trouble – and the expense.

Medicare.com provides coverage information that is simple and straightforward. We give you the medicare basics, as well as provide practical information and tools for making informed decisions on your coverage needs.

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To confront these problems, presidential hopefuls John McCain, Hillary Clinton and Barack Obama have all proposed extensive health care reform plans.

But some health care professionals believe that these proposals do not address the whole problem.

The United States is a nation living under medical apartheid. The South Florida Times summarized the studies’ findings as follows:

“… elderly black and Hispanic patients often received substandard care for common but serious conditions like heart attacks, congestive heart failure and pneumonia. Researchers say their data suggests

that the nation’s healthcare system is racially and ethnically segregated, not just for the elderly, but across the board.”

Lead researcher, Dr. Ashish K. Jha, said:

“When we see ongoing segregation in housing and education [in America,] it may not be surprising that we’re seeing very different administration of care in hospitals that serve blacks and Hispanics versus hospitals that mostly serve whites. But we’re not talking about [failures of] high tech medicine. This is basic stuff, like failing to administer aspirin or beta blockers to patients suffering a heart attack; treatments that we’ve known about for 20 years.”

These studies are consistent with earlier findings that, at all levels of incomes, black Americans die years earlier than whites. The infant mortality rate for African American babies is 2.5 times greater than it is for non-Hispanic whites, according to data from the National Center for Health Statistics, giving us the worst infant mortality rate of any industrialized nation on Earth except Latvia. It should be noted that these recent studies demonstrate that Hispanics in this country also experience extreme disparities in medical care.

Are you OK with that? Then how about this? Lack of health insurance results in the deaths of 18,000 Americans each year, according to studies compiled by the National Academies’ Institute of Medicine. That equates to 49 or 50 deaths every day. f you are plagued by concerns, anxieties, guilt, shame and despair over the health problems that people are facing….

It is estimated that nearly 90 million people – about one third of the population below 65 – spent a portion of either 2006 or 2007 without health coverage.

The percentage of people with employment-based health insurance has dropped from 70 percent in 1987 to 59 percent in 2006.

The number of uninsured children in 2006 was 8.6 million – or 11.7 percent of all children.

Nearly 3.5 million fewer children had health insurance in 2006 than in 2000.

Uninsured Americans get about half the medical care of those with health insurance. Compared to people with health insurance, the uninsured receive less preventive care, are diagnosed at more advanced disease states and once diagnosed, tend to receive less therapeutic care and have higher mortality rates.

About 18,000 unnecessary deaths occur each year due to lack of health insurance.

It is estimated that we have spent as a nation nearly 13.5 trillion dollars on health care since 2000, but this expenditure has not resulted in demonstrably better quality of care or better patient satisfaction compared to other nations.

It is estimated that we will have spent $2.2 trillion on health care services in 2007 – about 4.3 times the amount spent on national defense.

Health care spending is estimated to reach $4.2 trillion a year by 2016 – just eight years from now.

On average, health insurance premiums for employers have doubled since 2000.

Average out-of-pocket costs for co-payments, such as for prescriptions, deductibles and coinsurance for doctor visits, rose 115 percent between 2000 and 2006.

National surveys consistently show that the primary reason people are uninsured is because health coverage is too expensive.

In 2007, employer health insurance premiums increased by 6.1 percent -two times the rate of inflation and wage increases.

The annual premium for an employer health plan covering a family of four averaged nearly $12,100 in 2007.

The average employee contribution to company-provided health insurance increased more than 143 percent between 2000 and 2006.

It is estimated that nearly 700,000 patients have died in hospitals due to medical errors since 2000.

Unnecessary medical accidents, errors and poor quality are the nation’s third leading cause of death, just behind cancer and heart disease.

The Institute of Medicine estimates that nearly 100,000 patients die in hospitals each year due to medical errors. This is three times the number who die on the highways.

Recent studies show that only a little more than one-half of adult patients receive recommended care for their medical conditions.

It is estimated that 77 million Americans over the age of 19 have difficulty paying medical bills, have accrued medical debt, or both.

We have a current health care system that some 47 million Americans lack basic health coverage, while many who can afford coverage elect to do without because the deductibles are too high or the policies do not cover the treatments and procedures that they actually need. Medicaid offers health coverage for many low-income Americans, but not everyone qualifies for this system of government health care.

Average wages for working class Americans have not risen in parity with the ever-increasing health care premiums over the past six years, with some 11 million policyholders spending more than a quarter of their annual salary on health care expenses. Challenges readers to think past conventional wisdom and historical corrections for the future of Health care challenges.

Over the past six years, family health insurance premiums have risen on average about 69 percent, more than six times the increase in the median earnings of workers (about 11 percent), finds Families USA, a Washington group championing healthcare consumers.

This is not affordable for most families and individuals, forcing more and more to discontinue there coverages. Healthcare crisis is building momentum as more people elect not to maintain coverage for themselves and families. affordable coverage for healthcare is of growing concern for many americans.

Your gut started telling you something is not right, didn’t it?

Why do we have a crisis in health care costs today? Because government “solved” the last one.

Medical Insurance that Worked – Until Government “Fixed” It, I discussed the continuing health problems.

The best way to combat feeling bad about a terrible situation is to take positive action to do something good to correct it.

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Health care is an immediate issue that concerns all of us. We all experience it and need it. Let’s serious ask ourselves if the current health care system is satisfactory and available to everyone. Should health, medicare and treatments be available to only selected groups? Many people are voting for the presidential candidate who can restore the present health care system or who can pioneer a better healthcare distribution for our country. Personally, I hope to see a change that health care is available and affordable to everyone.

Being able to receive basic health care is a fundamental need of all people. Fulfilling this fundamental need makes people feel secured, and it makes sense that people with better health can contribute more to the society. A realistic and reachable standard of health should be set for all people. This effort needs a non profit driving entity to establish and to maintain it. People’s life and health should not be compromised for the profit of few organizations.

Before moving to Japan, I was covered under my parents’ insurance policy in the United States. Their policy covered children of the family until the age of twenty-four. Upon graduating from university, I moved to Japan and started my first job there. I joined the Japanese national health insurance through the company I worked for. There are basically two types of health insurance in Japan: national health insurance and employer-sponsored health insurance. Usually, under employer sponsored insurance, the insurance premium is calculated according to income, number of dependents, and the company’ subsidies. For someone who is self-employed or unemployed, the national health insurance costs a minimum of 13300 yen, or about $110 per month plus a small percentage of income for those who are self-employed. In other words, everyone can get insurance from around $100 dollars a month. Unlike the Medicaid program in the U.S. which is only available to certain low-income groups with specific requirements for eligibility, the Japanese health insurance is available to every citizen and legal residents. There is a ceiling to what the Japanese National insurance covers, but it covers all the basics and beyond.

In most cases in Japan, patients choose their doctor and hospital. There is no limitation to the doctors or hospital they can visit. This is a true competition among the clinics, hospitals, and medical practitioners, not for profit, but for quality. The same insurance that people have in Japan gives them the freedom to get second opinions and naturally eliminates those doctors whose practices are in question. The doctor visits, treatments, and medicine are not free; one is responsible for thirty percent of their medical bills. Japanese health costs are much lower than the costs in the United States. Thirty percent of the medical bill is still a reasonable amount one can afford. There are also special cases or categories of illness for which the insurance would give more coverage. If one is late on his payment, his insurance will not automatically be invalid. The insurance will still cover the person as long as he makes up the missed payments. After all, some people do run into difficulties in life at one point or another. Sounds to good to be true? Well, It’s real.

Taiwan, a place with no world recognition politically, has one of the top public health care system in the world. After moving to Taiwan due to my husband’s transfer a year a go, I learned and appreciated the system where universal or national health care is available to all more than ever. When speaking of universal, national, or pubic health insurance, people often turn their attention to the well-debated and discussed health care system in Canada. There are those whose views are negative, claiming that the medical service in a single-payer insurance system may not perform at its ultimate, and those whose views are positive, saying that they do not live in fear of ever having to face bankruptcy for outrageous medical bills. From my informal inquiries, more Canadian I came across favor their national health care system. Most of those who favor their national health care system commented that people of Canada are more secured in having their basic physical and psychological needs met.

In Taiwan, there is also government-sponsored universal health care for not only their citizens but also for foreign residents who live in Taiwan. Foreign residents can apply for the government-sponsored insurance after proving their legal status of residing in Taiwan. The insurance fee starts from the basic 600NT, or around $18 a month. For people in higher income brackets, their insurance is calculated based on a percentage of their income over the 600Nt. Fees are waived for retired soldiers, those who are physically challenged, and people who have economic disadvantages.

Interestingly, Taiwan’s national health insurance has only been established for little more than two decades, since 1985. The government policy-makers studied health care system from different foreign countries and composes the first Taiwan national health care from the ideas and methods of the system of other countries. It was said that Taiwan’s national insurance system is like a completed puzzle made from pieces of which fit its country and people. This insurance now covers the entire population, including foreign legal residents. According to research funded by Taiwan’s National Health Research and Taiwan’s Bureau of National Health Insurance, the cost of health care did not rise after the universal coverage was established (Jui-Fen & Hsiao, 2003.) What does that tell us?

A basic health care program can greatly reduce the consequences of illness left untreated. Basic health care does not mean free of charge or mindless spending without control. To build a healthy nation, we should take a closer look at the current U.S. health insurance. After all, a sound nation starts with the health of its people.

Writer’s Information:
The writer is a Chinese-American. After graduating from Queens College, New York, she moved to Japan and started teaching English as second language. In the 15years of living in Japan, she became a wife, a mother and a university lecturer. She continued her education after giving birth to her daughter and is now pursuing her ph.d in education. She is a positive person who is always looking forward to challenging new things. In Japan, many friends and students were affected by her words and encouragement, especially women. Using herself as examples, she encourages women to be a life time learner, open minded and to have self confidence. Now she is temporarily residing in Taiwan with her family.

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Aurora Health Care provides a service for both registered patients and those that are no registered as well. If you do register with them then you can request emergency and same day appointments as well as simply asking for advice from time to time. However, non-registered patients have to wait for appointments, although they can still make them as and when necessary. They cannot ask for emergency service, and so should actually call an ambulance if needed.

All Of Your Health Care Needs

Aurora Health Care does not stop at simply providing appointments. It can in fact take care of all of your needs, including providing convenient pharmacies. There are many Aurora Health Care pharmacies located around the country, thus making it easier to request a prescription or a refill as and when you like. You may find one on a high street, in a clinic or hospital, or even at your local supermarket if it is big enough to include several independent stores.

Aurora Health Care may host women’s services at a clinic or pharmacy too. Obviously women have more specialist problems than men do as a result of reproduction and so Aurora Health Care has quite rightly provided a specialist service that is dedicated to the health care of women as a result. Alongside that is a specialist service for seniors too. In old age, everybody’s health will dramatically decline over a period of time. This service deals with cancer, arthritis, mental degeneration and a whole host of other ailments that a senior may need from time to time or as a part of ongoing care.

Aurora Health Care also specializes in cancer care because the care for individuals with cancer is often neglected by health insurance companies. It can be so expensive and so draining on a family’s income that it is better to invest in health insurance that does cater for that eventuality.

Of course, Aurora Health Care is not just limited to the elements set out above but they are often the tings that individuals look for in a service. It is definitely worth considering Aurora Health Care because they cater for so many needs, including any that you may have right now!

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In-Home Care

In-home health care is the best option for people who have a higher level of fitness, and want to remain as independent as possible throughout their later years. In this situation, home health care nurses may come and visit you daily, or every couple of days, to take care of your everyday medical needs. Also, a housekeeper may be utilized, as well as a personal health care attendant, who would be responsible for more of the day-to-day living help – such as a companion, driver, cook or the like. In-home health care is quite easy to locate; just contact a nurses’ association or look in the Yellow Pages.

Continuing Care

An intermediary between nursing homes and independent living, continuing care, or retirement communities, offer a wide variety of health benefits and services to their inhabitants. These communities are usually all-inclusive, where dwellers receive lodging, meals, social events, varying levels of health care, and sometimes other perks as well.

Entrance fees for these establishments can be quite high (ranging from $10,000 to over 300,000); added to their monthly fees (ranging from $800-4000), and this option can prove to be expensive health care. However, services are guaranteed for the remainder of your life if you choose this option, and if your health falters, you can always be moved to the nursing home portion of their health care facility.

Because of the all-inclusive nature of this kind of health care, you’ll want to read the fine print carefully in your contract. What are all of the recurring and one-time fees? What exactly is covered with those fees? What health care options are, and are not offered? Do you need to purchase extra health insurance to cover your specific care costs? Also don’t forget to check up with the Better Business Bureau about the status of the facility you are interested in; if you plan on living there the rest of your life, you may want to double check it’s reputation, too.

Nursing Homes

In a very simple sense, nursing homes will take care of your health care needs when you are no longer able to. This may be for a short period of time while you are recovering, or for a longer period of time as you age. Nursing homes are the whole meal deal of health care for the elderly or otherwise incapacitated. If this is an option that you think you may require, there are many things to discuss and consider when looking at your options. Does the home provide the type of care that you will require? Research the history of the nursing home; are there any black spots on their record? Talk to people who have lived there, have used their services, or who are still living there now, if at all possible. Get their viewpoint.

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Poor access to health care is a problem for many special populations, and the reasons spans across the global community. According to Anderson, Rice and Kominski (2001) access to care is often assessed by existence of regular medical care and coverage of services, as well as by an absence of delays and barriers to care. Having a regular source of medical care is recognize as important for the general population, as well as for those with various chronic diseases (Anderson, Rice & Kominski, 2001 p.236). The poor, elderly, women, children and HIV/AIDS group are the most vulnerable groups in the world. The World Health Organization (WHO) indicate the next two decades will see dramatic changes in the health needs of the world’s populations with non-communicable diseases, mental illness, infectious diseases and chronic illness as leading causes of disability. Increases in the older population by up to 300% are expected in many developing countries; in addition, HIV/AIDS will continue to be a major cause of disability and death. These changes require a very different approach to health sector policy and health care services among the special populations of the world (WHO, 2006)

Special population needs

According to WHO, there were 390 million people aged over 65 years recorded in 1998, and this figure is estimated to double in 2025. With advances in medicine and prolonged life expectancy, the proportion of older people will continue to rise worldwide (WHO, 2006). Unfortunately fragile health and mobility, neglect and abuse are factors that increase the vulnerability of elder women and men. Al-Nasir and Al-Haddad (1999) suggest as the overall number of elderly people increase there is a corresponding rise in the number of older persons with disabilities. Such disabilities may be social, physical, mental or psychological. Data from the U.S. have estimated that 9.5 million, non-institutionalized individuals, experience difficulty in performing basic activities, such as walking, self-care and home management activities (Al-Nasir & AL-Haddad, 1999).

The elderly population and there needs has an enormous implications for health care system across the global. The financial infrastructure of nations must be prepared to accommodate the coming influx of elderly patient. According to Fried and Gaydos (2002) the aging population, has put enormous pressure on the Japanese health care system. The Japan’s has a unique fund for the elderly know as the Roken system. The Roken system is a pooling fund which attempts to distribute the burden of paying for geriatric care for all Japanese. Established in 1983, the pooling fund covers those who are more than 70 years old and bedridden people over 65 years old. The fund pools contributions from all insurance schemes. Seventy percent of medical costs for the elderly are covered by contributions from health insurance societies for company employees and national health insurance schemes and the government shoulders the remaining 30 percent (Fried and Gaydos, 2002 p. 251). One draw back to the Roken system is when the number of workers paying into the pooling fund is lower than the proportion of elderly people seeking assistance the system may not be sustainable.

In the U.S. the rapid growth of the elderly will put new stains on the financial resources of Medicare. Many older people who on fix incomes or limited financial resources may need a system as the Japanese Roken system, where health care is covered by contributions from health insurance companies or a universal social insurance scheme. The Medicare program has broad public support because it offers health security to many older and disabled people. Longest, Rakich and Darr (2000) suggest the need for a long-term approach to program financing, improved benefits and protections for people with low incomes remains an important issue to address. Medicare is facing the challenge of financing and managing health care for the growing number of Americans who will rely on this program for health insurance protection (Longest, Rakich and Darr, 2000). In the future the increasing growth of the elderly may pressure the government to set policies that resemble a cost sharing between private insurance and Medicare.

HIV/AIDS Group

According to Kates, Jennifer, Dorian, Richard, Crowely, Jeffers, Summers and Todd (2002) more than 60 million people have been infected with HIV worldwide, 20 million have died. HIV is now the leading cause of death in Africa and the fourth leading cause of death worldwide. Most of the impact has been felt in the developing world. Children and women are increasingly at risk. In addition, it is estimated that more than 40 million children will have lost one or both parents to HIV/AIDS by 2010 and these children will also be at increased risk for HIV (Kates, et. al, 2002). Access to treatment and available drugs are some of the unique health care needs facing the world HIV/AIDS population.

Fried and Gaydos (2002) indicate Cuba incidence of HIV/AIDS cases remains very low, although it is increasing as Cuba opens more to tourism and external contracts. Cuba once had a policy of quarantining for all HIV-positive cases. Pressures from international bodies such as the United Nations and many large nongovernmental agencies, Cuba now has a voluntary quarantine after medically recommended stay in a residency for eighth weeks. All newly identified people with HIV are also expected to spend at least eight weeks in a sanatorium (Fried & Gaydos, 2002). Cuba’s health system is funded primarily by the national budget through indirect taxation and duties. Cubans are expected to pay for all drugs for outpatient treatment. Access to health care treatment and services for HIV/AIDS patient therefore is very limited.

In the U.S. even a voluntary quarantine of newly HIV diagnosed patient would be a social injustice. As HIV progress in the U.S. individuals experience disability and unemployment due to the illness. Many HIV/AIDS patients rely on public entitlements and private disability programs for income maintenance and health care benefits. Medicaid and Medicare are the primary payers for individuals who are disabled. Anderson, Rice and Kominski (2001) suggest the lack of insurance and underinsure can represent formidable financial barriers to treatment for HIV/AIDS. Persons with HIV/AIDS are more likely than the general population to be uninsured or to have Medicaid insurance. Unlike Cuba in the U.S. AIDS medication is available to HIV/AIDS patient however not all medications are covered by insurance (Anderson, Rice & Kominski, 2001).

The financial burden of HIV infection increasing in communities is a financial burden on health care providers and public payers. The reliance on an infinite source of public funds for people with HIV/AIDS is in dout. Cuba is a communist country which developed a process of governmental quarantine for the HIV/AIDS population. The U.S. method of moving the HIV/AIDS patients into managed Medicaid health plans is a better process in which patient care is managed for the purpose of reducing the cost of treatment.

While gender affects the health of both men and women, WHO places special emphasis on the health consequences of discrimination against women that exist in nearly every culture. Powerful barriers including poverty, unequal power relationships between men and women, and lack of education prevent millions of women around the world from having access to health care and from attaining and maintaining the best possible health (WHO, 2006).

Anderson, Rice and Kominski (2001) indicate in Israel the waves of immigration in the early twentieth century sparked the establishment of networks of community welfare and health organizations. The sick fund model of health provision has persisted in Israel to this day. Although the 1994 National Health Insurance (NHI) Law made all sick funds regulated subcontractors of the state, thereby providing health care services to the country’s residents under government regulation (Anderson, Rice & Kominski, 2001). The system has been developed through voluntary sick funds, not for profit institutions, and the state. Israeli health system stem from organized social arrangements in which the government is responsible for the health of its citizens. The state has an active role in the development and financing of health care services that extend into the private sectors.

In the U.S the entrepreneurial system is more concern with the cost and the profit involve in providing health care for individuals. The Israel NHI is a system of collaborative efforts on subcontractors of the government. The process of subcontracting allows the government to oversea the implementation of health care activities through out the country. In the U.S. entrepreneurial system subcontracting by the government would give too much control over the health care system. The Israel system can not be applied readily to the U.S. health care system because there are no true national mandates that can be applied to an entrepreneurial system. Anderson, Rice and Kominski (2001) indicate in the U.S. individuals or employers may purchase private health insurance. Approximately 63 percent of Americans had private health insurance between 1977 and 1999. Of those with private insurance, 58 percent obtained health insurance through their employer, and 5 percent purchased insurance individually. Private health insurance companies may operate as for profit or not for profit organizations (Anderson, Rice & Kominski, 2001). Private health insurance organization with in the U.S. would fight against a system such as Israel NIH. The NIH is a allows Israel to regulate the health care system by subcontracting this type of system would cut the profit margin of private health insurance companies in the U.S.

Conclusion

Rising health insurance costs and high numbers of uninsured citizens has generated a public interest in national laws that would provide access to care for special populations. When evaluating Non-US health care concepts there is no one systems that guarantee universal access to health care for all. The national health care policy in the U.S. has evolved incrementally over the decade. Access to care has generally depended on insurance coverage that is implemented privately or publicly. With the increase needs of special populations the U.S. will have to establish policies that allow the collaboration between private as well as public entities to secure access for those in need.

References

Al-Nasir, F. & Al-Haddad, M. K. (1999). Levels of disability among the elderly in
Institutionalized and home-based care in Bahrain: Eastern Mediterranean Health Journal (5) p. 247-254 Retrieved March 3, 2006 from [http://www.emro.who.int/publications/emhi/0502/05.htm]

Anderson, R. M., Rice, T. H., & Kominski, G. F. (Eds.). (2001). Changing the U.S. health care
system: Key issues in health services Policy and management (2nd ed.). San Francisco:
Jossey-Bass.

Fried, B. J., & Gaydos, L. M. (Eds.). (2002). World health systems: challenges and perspectives.
Chicago: Health Administration Press.

Kates, Jennifer, Sorian, Richard, Crowely, Jeffrey S., Summers & Todd, A. (2002). Critical
policy challenges in the third decade of the HIV/AIDS epidemic. American Journal of Public Health (92) Issue 7 Retrieved March 3, 2006 from [http://web14.epnet.com/citation.asp?tb=]

Longest, B. B., Rakich, J. S. and Darr, K. (2000) Managing health services organizations and
systems (4th ed.). Baltimore, MD: Health Professions Press, Inc.

World Health Organization (2006). Important target groups Retrieved March 2, 2006 from
http://www.who.int/oral_health/action/groups/en/print.html

Bio- Dr. Gilton C. Grange

Dr. Gilton Grange’s formal education includes a Doctorate of Philosophy in Health Administration from the University of Phoenix, A Master of Public Administration from Long Island University and A Bachelor of Arts degree fro State University of New York at Buffalo. Dr. Grange has 12 years extensive experience in the Health Care arena and currently has concentrated his efforts in grant writing and grant development for organizations that seek to grow their businesses. Dr. Grange’s company BridgeBuilder Consortium provides services in proposal writing, management and costing for firms and organizations bidding on government contracts and grants. Dr. Grange is currently working on his first comprehensive book that focuses on multi-disciplinary teams in an organizational construct.

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Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ’sleight-of-hand’ precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

- “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

- The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

- DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

- REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…

- REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

- PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

- PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Provider Fraud Consultants, Inc., dba Chiropractic Compliance Consultants, Inc., 18065 238th Street, Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com

Article Source: http://EzineArticles.com/?expert=Daniel_J_Osborne

The National Coalition on Health Care (NCHC) reports that total spending on health care was $2.3 trillion last year, equivalent to $7600 per person. Health insurance premiums for a family of four sky rocketed to $12,100 during this same period and single coverage premiums averaged more than $4,400 annually.

One tactic to save on health care is to buy high deductible “catastrophic” health insurance which is significantly less expensive (as much as 50%-75% less) however this strategy must be combined with a commitment towards exercise and a healthy lifestyle.

The good news is that exercise does not have to be overly strenuous. The Centers for Disease Control (CDC) report that walking three times per week for a minimum of 30 minutes reduces the risk of mortality from disease by 57%.

Unfortunately 2/3 of the American population is now categorized as overweight according to the CDC and less than 10% of the population is exercising on a regular basis. While Congress must focus on ridding our health care system of excessive administrative costs, fraud and mismanagement there must also be a call for personal action. Prevention through a healthier lifestyle and exercise should play an integral role in our growing health care crisis but few politicians wish to risk the backlash of telling Americans they need to get out of their chairs and start moving.

Desperate for answers, some state governments are considering instituting a “carrot and stick approach” to medical insurance programs. Alabama recently enacted a $300.00 annual increase for health care premiums to state employees that do not meet minimum health requirements and are unwilling to join their state wellness plan. Other nations are instituting more stringent guidelines as well. Japan has implemented a national program fining corporations if their employees do not meet specific weight and waistline guidelines.

Rising health care costs and insurance premiums are taking the availability of health care out of the hands of millions and placing a tremendous burden on our economy according to the NCHC, accounting for approximately 16% of our current GDP and expected to rise to 20% of GDP in eight years.

Now that health care costs are rising at 2-3 times the rate of inflation an emphasis on prevention seems more critical now more than ever before. Treadmill desks offer a solution which empowers employees to take control of their personal health and reduce their costs of medical care at the same time.

ABOUT TrekDesk – manufacturer of the first affordable full sized, adjustable treadmill desks designed to fit your existing treadmill and allow you to walk while you work, burn calories without sweating and enhance your health.

Article Source: http://EzineArticles.com/?expert=Steve_Bordley

These days, adverts for insurance are everywhere. There are numerous adverts on TV, radio and in magazines. There are even various ones on the Internet that you can look into further, but very few of these adverts on any medium will advertise the long term health care benefits. You have to delve a little deeper to get a good picture of them. The sheer choice will also baffle you because you will be inundated with information about products that you can neither distinguish nor effectively examine. You should note the reputable companies and make a short list, and then delve into the world of long term health care. You should actually contact the companies and ask specifically about long term health care for in depth information.

You should ideally compose a list of all of your wants and needs where long term health care is concerned before delving into conversation with any representative of insurance companies because the cover can be very basic but any good sales person can make it sound incredibly good. By having a list of wants and needs concerning your long term health care, you can compare what they have to say with that. You should always do some online research to see what elements of long term health care should, by rights, be receiving regardless of the insurance policy you take out and also what cover you should be looking for.

Do not be afraid to play companies off against one another by comparing their policy to others that offer long term health care options. You should try to get as much out of a company as you possibly can because it is your health, which is very precious after all. As long as you do your research, you can make sure that you get a great deal for your money… and your long term health care!

You can also find more info on Health Care and Affordable Health Care. Tophealthcarehelp.com is a comprehensive resource to know about Health Care.

Article Source: http://EzineArticles.com/?expert=Wade_Robins