Occupational Health – Workplace Health Management

Workplace Health Management (WHM) There are four key components of workplace health management:

Occupational Health and Safety
Workplace Health Promotion
Social and lifestyle determinants of health
Environmental Health Management

In the past policy was frequently driven solely by compliance with legislation. In the new approach to workplace health management, policy development is driven by both legislative requirements and by health targets set on a voluntary basis by the working community within each industry. In order to be effective Workplace Health Management needs to be based on knowledge, experience and practice accumulated in three disciplines: occupational health, workplace health promotion and environmental health. It is important to see WHM as a process not only for continuous improvement and health gain within the company, but also as framework for involvement between various agencies in the community. It offers a platform for co-operation between the local authorities and business leaders on community development through the improvement of public and environmental health.

The Healthy Workplace setting – a cornerstone of the Community Action Plan.

The Luxembourg Declaration of the European Union Network for Workplace Health Promotion defined WHP as the combined effort of employers, employees and society to improve the health and well-being of people at work

This can be achieved through a combination of:

Improving the work organization and the working environment
Promoting active participation of employees in health activities
Encouraging personal development

Workplace health promotion is seen in the EU network Luxembourg Declaration as a modern corporate strategy which aims at preventing ill-health at work and enhancing health promoting potential and well-being in the workforce. Documented benefits for workplace programs include decreased absenteeism, reduced cardiovascular risk, reduced health care claims, decreased staff turnover, decreased musculoskeletal injuries, increased productivity, increased organizational effectiveness and the potential of a return on investment.

However, many of these improvements require the sustained involvement of employees, employers and society in the activities required to make a difference. This is achieved through the empowerment of employees enabling them to make decisions about their own health. Occupational Health Advisors (OHA) are well placed to carry out needs assessment for health promotion initiatives with the working populations they serve, to prioritize these initiatives alongside other occupational health and safety initiatives which may be underway, and to coordinate the activities at the enterprise level to ensure that initiatives which are planned are delivered. In the past occupational health services have been involved in the assessment of fitness to work and in assessing levels of disability for insurance purposes for many years.

The concept of maintaining working ability, in the otherwise healthy working population, has been developed by some innovative occupational health services. In some cases these efforts have been developed in response to the growing challenge caused by the aging workforce and the ever-increasing cost of social security. OHA’s have often been at the forefront of these developments.

There is a need to develop further the focus of all occupational health services to include efforts to maintain work ability and to prevent non-occupational workplace preventable conditions by interventions at the workplace. This will require some occupational health services to become more pro-actively involved in workplace health promotion, without reducing the attention paid to preventing occupational accidents and diseases. OHA’s, with their close contact with employees, sometimes over many years, are in a good position to plan, deliver and evaluate health promotion and maintenance of work ability interventions at the workplace.

Health promotion at work has grown in importance over the last decade as employers and employees recognize the respective benefits. Working people spend about half of their non-sleeping day at work and this provides an ideal opportunity for employees to share and receive various health messages and for employers to create healthy working environments. The scope of health promotion depends upon the needs of each group.

Some of the most common health promotion activities are smoking reducing activities, healthy nutrition or physical exercise programs, prevention and abatement of drug and alcohol abuse.

However, health promotion may also be directed towards other social, cultural and environmental health determinants, if the people within the company consider that these factors are important for the improvement of their health, well-being and quality of life. In this case factors such as improving work organization, motivation, reducing stress and burnout, introducing flexible working hours, personal development plans and career enhancement may also help to contribute to overall health and well-being of the working community.

The Healthy Community setting In addition to occupational health and workplace health promotion there is also another important aspect to Workplace Health Management. It is related to the impact that each company may have on the surrounding ambient environment, and through pollutants or products or services provided to others, its impact on distant environments. Remember how far the effects of the Chernobyl Nuclear accident in 1986 affected whole neighbouring countries.

Although the environmental health impact of companies is controlled by different legislation to that which applies to Health and Safety at work, there is a strong relationship between safeguarding the working environment, improving work organization and working culture within the company, and its approach to environmental health management.

Many leading companies already combine occupational health and safety with environmental health management to optimally use the available human resources within the company and to avoid duplication of effort. Occupational health nurses can make a contribution towards environmental health management, particularly in those companies that do not employ environmental health specialists.

Community Needs Health Assessment

In 2012 the Internal Revenue Service mandated that all non-profit hospitals undertake a community health needs assessment (CHNA) that year and every three years thereafter. Further, these hospitals need to file a report every year thereafter detailing the progress that the community is making towards meeting the indicated needs. This type of assessment is a prime example of primary prevention strategy in population health management. Primary prevention strategies focus on preventing the occurrence of diseases or strengthen the resistance to diseases by focusing on environmental factors generally.

I believe that it is very fortunate that non-profit hospitals are carrying out this activity in their communities. By assessing the needs of the community and by working with community groups to improve the health of the community great strides can be made in improving public health, a key determinant of one’s overall health. As stated on the Institute for Healthcare Improvement’s Blue Shirt Blog (CHNAs and Beyond: Hospitals and Community Health Improvement), “There is growing recognition that the social determinants of health – where we live, work, and play, the food we eat, the opportunities we have to work and exercise and live in safety – drive health outcomes. Of course, there is a large role for health care to play in delivering health care services, but it is indisputable that the foundation of a healthy life lies within the community. To manage true population health – that is, the health of a community – hospitals and health systems must partner with a broad spectrum of stakeholders who share ownership for improving health in our communities.” I believe that these types of community involvement will become increasingly important as reimbursement is driven by value.

Historically, healthcare providers have managed the health of individuals and local health departments have managed the community environment to promote healthy lives. Now, with the IRS requirement, the work of the two are beginning to overlap. Added to the recent connection of the two are local coalitions and community organizations, such as religious organizations.

The community in which I live provides an excellent example of the new interconnections of various organizations to collectively improve the health of the community. In 2014 nine non-profits, including three hospitals, in Kent County, Michigan conducted a CHNA of the county to assess the strengths and weaknesses of health in the county and to assess the community’s perceptions of the pressing health needs. The assessment concluded that the key areas of focus for improving the health of the community are:

· Mental health issues

· Poor nutrition and obesity

· Substance abuse

· Violence and safety

At this time the Kent County Health Department has begun developing a strategic plan for the community to address these issues. A wide variety of community groups have begun meeting monthly to form this strategic plan. There are four work groups, one for each of the key areas of focus. I am involved in the Substance Abuse workgroup as a representative of one of my clients, Kent Intermediate School District. Other members include a substance abuse prevention coalition, a Federally qualified health center, a substance abuse treatment center and the local YMCA, among others. The local hospitals are involved in other workgroups. One of the treatment group representatives is a co-chair of our group. The health department wants to be sure that the strategic plan is community driven.

At the first meeting the health department leadership stated that the strategic plan must be community driven. This is so in order that the various agencies in the community will buy into the strategic plan and will work cooperatively to provide the most effective prevention and treatment services without overlap. The dollars spent on services will be more effective if the various agencies work to enhance each others’ work, to the extent possible.

At this time the Substance Abuse work group is examining relevant data from the 2014 CHNA survey and from other local resources. The epidemiologist at the health department is reviewing relevant data with the group so that any decisions about the goals of the strategic plan will be data driven. Using data to make decisions is one of the keystones of the group’s operating principles. All objectives in the strategic plan will be specific, measurable, achievable, realistic and time-bound (SMART).

Once the strategic plan is finished, the groups will continue with implementation of the plan, evaluating the outcomes of the implementation and adjusting the plan as needed in light of evaluation. As one can see, the workgroups of the CHNA are following the classic Plan-Do-Check-Act process. This process has been shown time and again in many settings-healthcare, business, manufacturing, et al-to produce excellent outcomes when properly followed.

As noted above I recommend that healthcare providers become involved with community groups to apply population level health management strategies to improve the overall health of the community. One good area of involvement is the Community Health Needs Assessment project being implemented through the local health department and non-profit hospitals.

Sexual Health of Men!

The sexual health of men is not as complicated as that of women. Show a man a certain type of image and if his brain and nervous system are working properly to produce nitric oxide, then a response will usually occur. That’s not to discount any mental, emotional, and spiritual components but it is the physical component that has the greatest impact on man’s sexual health. This article will focus on what men can do to improve the physical component of their sexual health. The side benefit is that these suggestions can also positively impact your overall wellness and how you age.

In all the information I gathered to prepare for this article, two overriding issues kept surfacing. These two health issues were consistently present. The first is hormone levels. The second is cardiovascular health. Most men would understand how hormone levels could apply but few ever consider cardiovascular health.

Cardiovascular Health!

Your cardiovascular health is as important to your sexual health as it is to your overall health. The reason why centers on the health of the endothelial cells that line the blood vessels of your body. The creation of nitric oxide occurs in these endothelial cells. Nitric oxide researchers believe that nitric oxide can correct up to 90% of all penile dysfunction. When the endothelial cells are damaged by high blood pressure, high sugar levels, cholesterol, and smoking this decreases nitric oxide production. Endothelial cells and their ability to produce nitric oxide are critical to the sexual health of men.

Hormone Levels!

At its simplest level, sex is just a hormone driven function designed to perpetuate the species. With that said, the sexual health of American men is in trouble. Testosterone levels have been decreasing over the last 20 years. Testosterone is the primary male sex hormone. It plays an important role in maintaining bone and muscle mass. Low levels of testosterone have been linked to lowered libido and diabetes. Diabetes can affect the endothelial cells of the blood vessels compounding the problem of lower testosterone levels.

Over the past two decades, the level of testosterone in American males has decreased by 16 percent. Researchers don’t know why. But there are some clues. The recent Nurses’ Health Study revealed some important truths as they apply to women. Some of those truths also apply to the sexual health of men because they affect both hormonal levels and cardiovascular health.

Additionally, as testosterone levels have decreased this has resulted in reduced muscle mass and tone, reduced metabolism and energy and an increase in body fat. Not a sexy combination! You can accept it and do nothing about it. Or, you can begin to live life by making healthier eating and exercise choices. Choices that will help your body actually be younger physically than your chronological age.

You Have Control Over the Process!

Every day you replace approximately 1% of your cells. That means that 1% of your body is new today, 1% is new tomorrow, and 1% is new each and every day of your life. You choose whether those new cells will be nourished properly or poorly. You choose whether you will have healthy and vibrant cells that act young. Or, sickly and sedentary cells that act old.

The sexual health of your body will be affected by the choices you make. I call it “The 1% Solution!” and it will positively affect the cardiovascular and sexual health of your body.

Choices Affecting Sexual Health!

The Nurses’ Health Study highlighted five critical lifestyle and diet behaviors. They are:

o Carbohydrates – Slow verses Fast!

o Fats – Natural verses Artificial!

o Protein – Animal or Plant!

o Body Weight – Your BMI!

o Exercise – Is It Important?

If you look at this list, three critical components emerge: Diet, Weight, and Exercise! Now you might think that this only applies to women. It doesn’t! Each of these factors will affect your cardiovascular health and hormonal balance. Each of these factors also affects the health of your endothelial cells and their ability to produce nitric oxide. Nitric oxide production is the most important component to the sexual health of men. Let’s look at how all of these factors impact your sexual health.

The Diet Component!

You are what you eat and drink. The sexual health of your body and the cardiovascular health of your circulatory system will be greatly determined by your food and drink choices. These choices will also impact the potential for disease and how you age.

Your first choice is in the area of carbohydrates. Are you choosing foods and drinks that are high in fast carbs (simple sugars)? If you are, then you need to understand that:

o Fast carbs disrupt hormone levels.

o Fast carbs create the potential for high blood sugar that can lead to diabetes.

o High blood sugar can damage the endothelial cells of your blood vessels reducing the production of nitric oxide which is critical for good sexual and cardiovascular health.

Learn to consume foods that are high in slow carbs (complex carbohydrates). Slow carbs will help to keep your blood sugar levels normal and your hormonal levels balanced. Drink water instead of sugary drinks and diet sodas. Drinking water hydrates your system, helps you balance your hormone levels, and aids in weight management.

Your second choice is in the area of fats. Eliminate all trans fats from your diet and replace them with natural, heart-health fats. The Nurses’ Health Study clearly showed how disruptive trans fats are to fertility in women. As little as four grams of trans fat (the equivalent of two tablespoons of stick margarine, one medium order of French fries or one doughnut) began to disrupt their hormonal balance.

How much of your diet consists of trans fats from fast food restaurants? How many orders of French fries and doughnuts have you consumed at work? Although I can’t give you any hard research on men, it makes sense that we can be as affected by trans fats as women are. It’s time that you incorporate foods that are rich in omega-3 fatty acids (such as wild, cold-water fish, walnuts, and flax seeds) since essential fats help to balance hormone levels and promote healthy cell function.

Your third choice is in the area of protein. According to the Nurses’ Health Study, women who got their protein from plant sources rather then from animals took a big step toward improved fertility. Animal protein can adversely affect your sexual health. It also has a direct influence on cancer!

If you’re not willing to give up your beef, pork or chicken, then invest the time, energy and extra cost to make sure that these sources of protein are hormone free. This also applies to your dairy products. Much of the industry still relies on hormonal injections into their livestock to help increase food production. Eating meat from these animals and their byproducts will affect your hormonal levels. If you’re not willing to switch to plant-based protein sources, then make sure your meat and dairy sources are hormone free.

The Weight Component!

Like it or not weight impacts the sexual health of your body. Why? Because fat interferes with your hormonal balance! Fat also stresses your cardiovascular system. This additional stress on your cardiovascular system will compromise the sexual health of your body. Currently, 66% of Americans are overweight with at least a third being obese. Diets are not the answer. America has been dieting for the last 50 years. It has had no real impact on slowing down overweight and obesity rates.

You need a paradigm shift from “dieting” to “healthy eating”. Make food choices based on how it will improve your health and wellness, not on how it will impact your weight. Most people who do this see their weight stabilize or decrease.

The Exercise Component!

Exercise is important for both sexual and cardiovascular health. Inactivity saps the body of its ability to respond to insulin and makes you less efficient in absorbing blood sugar. A study from the Electronic Journal of Human Sexuality highlighted that people who exercised on a regular basis:

o Feel better about themselves.

o Think they are more sexually desirable.

o Experience greater levels of satisfaction.

It’s always important to check with your physician or health care provider before you start an exercise program. Once you have their OK, than strive to get at least 30 minutes of exercise per day. Aerobic exercises like walking, jogging, biking, and swimming are important and seem to increase circulation to the pelvis and the reproductive organs. But don’t forget about strength training exercises. Strength training exercises will help you maintain bone health and density. Additionally, strength training exercises will increase your spatial awareness. This is a very positive feeling that improves your overall well being.

The Nitric Oxide Component!

You cannot live without nitric oxide. Your cardiovascular system could not function properly without nitric oxide. The sexual health of your body revolves around the production of nitric oxide. Nitric oxide production is dependent upon the health of the endothelial cells of your blood vessels, and adequate supplies of the essential amino acid L-arginine.

High blood pressure, high sugar levels, high cholesterol levels and smoking all affect your endothelial cells in a negative way. Damage to these endothelial cells will reduce nitric oxide production. This can compromise the blood flow to the sexual organ resulting in reduced sensitivity and/or erectile dysfunction.

Since nitric oxide is synthesized from the essential amino acid L-arginine, your diet needs to include protein sources and/or supplements that contain this amino acid. It needs to be emphasized that L-arginine is not a hormone and it is not testosterone. However, when properly brought into the body it can cross the blood-brain barrier to signal the hypothalamus to naturally trigger the pituitary gland to produce growth hormone. This is the key to eliminating any negative side effects typically associated with hormone supplements like DHEA and HGH.

Please note that L-arginine has a dark side and can cause some serious side effects. Read my article, “L-arginine, Nitric Oxide and Sexual Health!” for more information on this essential amino acid.

Conclusion!

If you continue a life of inactively, animal protein intake, sugary drinks, foods made from refined grains, increased body fat, and inadequate nitric oxide production, then you will become part of the new reality for America. This new reality includes epidemic increases in diabetes, continued high levels of cardiovascular disease and stroke, continued high levels of cancer, and poor sexual health especially for those over the age of 40. As Aristotle said, “We Are What We Repeatedly Do!”

By taking the necessary steps to improve your diet, manage your weight, exercise properly and increase your body’s ability to produce nitric oxide you will experience positive changes in the sexual health of your body. If you repeatedly take these positive steps you will also improve your wellness and slow down your aging.

One Final Thought!

Although the hormonal balance between men and women are different, the process of change is the same. Many of the steps that improve the sexual health of men will also help improve the sexual health of women. Encourage your spouse or partner to implement these changes with you. If you both take the steps to improve your health, then you will both be reward in the bedroom, and in living your life to its fullest.

Government-Run Health Care Cannot Work!

It would be GREAT if our government could successfully manage American’s Health Care needs. I would be all in if the government guaranteed good health for everyone, and they were even remotely qualified to make such a guarantee. The truth is we all face different health issues at different ages. The recent health issues I faced were handled by doctors, hospitals, and nurses. I had made poor food and exercise choices and suffered a stroke because of those poor choices. Health professionals guided my recovery and no person from the government or from the health insurance company ever visited me while I was hospitalized or in recovery. The task of defining what a health care system looks should be determined by you and your doctor, not the health insurance companies, government, and lawyers that are currently the face of our health system.

The government, i.e. politicians, claim we all need health insurance, but who will pay for the premiums, co-pays, and not-covered illnesses and accidents? Will everyone enjoy good health because they a health insurance policy? Will everyone’s health insurance be free since the ACA has mandated everyone own a policy regardless of their individual health needs or financial position? Basically, at gun-point, ‘rhetorically speaking,’ the government is forcing everyone to purchase health insurance? If legal, where will the money come from to pay the health insurance premiums, or the health professionals who diagnose our illnesses? Where will the money come from to finance the equipment needed to diagnose and/or treat our health needs? Where will the money come from for the buildings needed to house the equipment and the facilities for the infirmed? These are just a few of the questions I have for those who profess the government should be responsible for our individual health needs. The last time I checked the government didn’t have any money to pay for anything unless they taxed you and me to get it.

What, you mean we already have a government-run health care system? Is that why my taxes are so high? Is that why I read in the newspaper recently that the government is paying millions of dollars every year for fraudulent health care claims? Is that why doctors are leaving the government-run health system for the more efficient private practices? Is that why the government is making criminals out of Americans who would rather not purchase health insurance policies? Golly, I hope the government does a better job of running Obamacare than they did managing health needs for our veterans through the Veterans Administration.

Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

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.

Telemedicine in the Affordable Health Care Act Explained

Telemedicine is an important component of the robust and technology driven Affordable Care Act system (Obama care) and provides avenues for reducing costs in the new healthcare structure, because it offers options in how to access healthcare services.

The Affordable Care Act is the most comprehensive overhaul of the nation’s health care system in decades and it’s implementation and sign-ups will all be processed through marketplace exchanges.

What is the Meaning of Telemedicine?

Telemedicine is the use of telecommunication and information technology to provide clinical health care without a traditional face-to face consultation. It helps eliminate distance barriers and can improve access to supplementary medical services for people with:

Basic or No Insurance
High Deductible (HDHP) Insurance
Traditional Insurance

Tele-health Vs Telemedicine

‘Tele-health’ is an older, broader term for services such as health education and is not limited to clinical services, while ‘Telemedicine’ narrowly focuses on the actual curative aspect between the patient and healthcare professional. Examples of Tele-health are health professionals discussing a case over the telephone or conducting robotic surgery between facilities at different ends of the world.

Tele-Health has a broader scope than telemedicine and is sometimes called e-health, e-medicine, or telemedicine. Health care professional use tools like e-mails, e-visits, e-prescribing, after-hours care, e-reminders, health assessments, self-management tools, health coaching etc.

The State of the Market

The Affordable Care Act (Obama Care) Health Insurance Exchange (HIX) opens on Oct 1st, 2013. and goes into operation on Jan 1st, 2014. The Obama Care exchanges, are State, Federal or joint-run online marketplaces for health insurance. Americans can use their State’s “Affordable” Insurance Exchange marketplace to get coverage from competing private health care providers.

Steps to Sign up for Health Care Plans

Participants enter personal information into a web portal
Learn their eligibility for subsidies based on income, state-determined criteria or employer-based options.
Use a price calculator to shop, compare and choose a best benefit health plan.

Several major health companies have programs like TelaDoc in Aetna, KP-OnCall in Kaiser etc, trying to set up footholds in a market that is widely expected to grow rapidly. All participants have to do is research for telemedicine benefits through their health insurance plans or sign up for independent programs.

How Health Care Professionals Administer Telemedicine

Doctors can treat most everyday health needs by phone or a scheduled video consultation. A study by the American Medical Association shows that 4 out of 5 visits to a primary care doctor could have been treated over the phone instead. After each consultation, patients will receive a clinical report which can be emailed to a primary care physician.

Registered Nurses manage triage calls and act as health coaches. For some specific symptoms, they give guidance for the most appropriate care, and over 32% of the time will offer self-care options so patients avoid a visit to the doctor, ER or Urgent Care facility entirely.

Common symptoms often treated through Telemedicine

Respiratory Infections, Cold/Flu Symptoms, Urinary Tract Infections, Sore Throats, Headaches/Migraines, Sinusitis, Allergies, Insect bites, Certain Rashes, Sprains/Strains, Arthritic Pain, Stomach Aches/Diarrhea, Gastroenteritis, Minor Burns and many non-emergency medical conditions

By 2014, the law mandates that all non-exempt Americans have health insurance or face a tax penalty. The Affordable Care Act has far-reaching advantages such as prohibiting insurance companies from dropping a clients’ coverage if they get sick or discrimination against anyone with a pre-existing condition and extending children’s eligibility on parent’s plans.

For entrepreneurs, who will most likely be responsible for their own health insurance, knowing how telemedicine can supplement their health insurance plans, means they can take full advantage of the options, savings and benefits.

Determining the Health Needs of Men: Promoting Men As Health Heroes

Increased health and wellbeing into the senior years

Generally amongst populations of different countries, men have a lower life expectancy than women. With a lot of discussion in many political arenas of increasing the age of retirement, it is becoming increasingly necessary for men to take charge of improving their health. Quality of life, and increased functionality and mobility should be normal as men age, not a slow decline of health. Men can do much to be a health hero, and increase their potential for increased physical strength, functionality and mobility and healthy mental faculties well into their senior years.

Health Heroes have Health Checks

Primary or preventive health for men helps them become aware of what they need to do in order to reduce the risk of developing a chronic disease as they get older. A visit to the local general practitioner for an annual or bi-annual health screening check will help ensure that the man will be aware of all his vital statistics. These include blood pressure, HDL and LDL cholesterol levels, heart health, liver health, lung health, digestive system health, cancer free status and levels of nutrients in the blood. The GP can also discuss mental health, and how his reproductive organs and sexual wellbeing are going.

Men and Mental Health

A lot of men are unsure of how to approach mental health with their doctor or health practitioner. They are more likely to describe symptoms of depression such as lethargy and tiredness, and lack of motivation, rather than using diagnostic terms such as “depression.” There is much being done to alleviate the stigma attached to mental illness, and the promotion of mental health and the importance it has attached to the rest of the health of the body is being emphasized among various international health promotion campaigns. Men in rural areas, and remote areas are particularly vulnerable to symptoms such as depression and anxiety, and they have concern as to how they can provide for their families if they are working in rural environments. Many countries have specialist telephone counseling services for men, and it is extremely important for men to access these telephone counseling services should they have any concerns about themselves, their families or their jobs. If men have been feeling unusually tired and unmotivated, it is important to talk to the doctor about it, and the doctor will keep everything completely confidential. Treatment for symptoms of lethargy may include medicine prescriptions, however there are other options such as counseling, and lifestyle modification including playing more social sport, and eating more fruit and vegetables. Tiredness and lethargy can be an indicator of a low level of iron stores or some other health issue, so it is important to undergo health screening to help restore health and wellbeing.

General Health and Wellbeing

A general healthy lifestyle which includes a healthy diet, six to nine hours sleep per night, abstinence from daily tobacco use, no more than two alcoholic drinks per day and several days per week without alcohol, and regular exercise of at least 150 minutes over 5 sessions per week will significantly reduce the risk factors for men developing health problems. Primary and preventive care makes men responsible for choosing healthy behaviors, and encouraging these healthy activities among their friends. Healthy male friendships include sports teams and social clubs from work. There are usually men’s shed type activities attached in some communities to church organizations. They cater specifically to men’s interests. It is important to have interests and hobbies outside the home, to promote health and mental wellbeing. A man does not have to be a gym junkie to be healthy, but a generally healthy lifestyle will help him perform well in all areas including in enjoying his sex life.

Men and Sexual Health

When a man is healthy and his cardiovascular system is working properly, he will have no difficulty in getting and maintaining an erection. He should also have no trouble urinating in a strong stream. If a man has any issues or concerns about his sex life, including maintaining an erection, or difficulty urinating, he can discuss these problems confidentially with his doctor in order to help regain his confidence in the bedroom. Sex in a healthy committed relationship has been shown to be ideal for optimum mental wellbeing, and a man should also practice safe sex with his sex partners. Any discussion of these issues can be discussed confidentially with a doctor.

How Smoking Impacts Your Health Insurance Policy

It’s a well-known fact that smoking causes an adverse effect on your health. You must have seen the warning message on all cigarette boxes – ‘Smoking is injurious to health’. Smoking tobacco is a root cause of 30% of all cancer deaths and causes 16 times higher risk of heart attack.

There are almost 120 million smokers in India. As per World Health Organization, India accommodates around 12% of the world’s smoking population. The number of men smoking tobacco has increased from 78 million in year 1998 to 108 million in the year 2015. Tobacco consumption is accountable for the death of 6 million people each year. Direct tobacco consumption accounts for over 5 million deaths and 0.6 million deaths are due to exposure to second-hand smoke. Considering serious public health risks, the Government has banned smoking in public places from 2nd October, 2008.

Not only your health, it also causes you to pay higher premiums for a health insurance policy, due to increased health risks and shorter life expectancy. A nonsmoker however, gets premium discounts as a reward to lead a healthy lifestyle. Being a smoker, it is advisable not to hide your smoking habit from your health insurance company, as it helps you to cover the smoking-related health issues.

There is a wide curiosity among people, how smoking impacts the health insurance and its cost. Let’s educate yourself about smoking and its impact on health insurance policy.

Smoking – What It Includes

Smoking includes inhalation of of the smoke of burning tobacco in the form of cigarettes, cigars and beedi. Whether you are an occasional smoker or frequent smoker, you will be considered as a smoker under the health insurance policy.

Smokers can buy health insurance, however an insurance company may charge extra premium or reject your application for insurance, depending on the number of cigarettes you smoke on a regular basis. A smoker may also have to go through additional health check-ups that can help an insurance company to ascertain the risk factor and then charge the premium amount accordingly.

How Smoking Affects Your Health and Insurance Premium

Smoking makes the serious impact on your health, some of them are detailed below.

Circulatory System: Smoking results in increased risk in the heartache and blood pressure. Building up of fatty acids could resulting to atherosclerosis.

Immune System: Smoking results in severe and long lasting illnesses. Smokers are more prone to develop ulcers, cancer, pneumonia, high blood pressure, bronchitis, and other viral/bacterial/fungal infections.

Respiratory System: Smoking may damage lung functions and breathlessness. It may cause damage to the air sacs of the lungs, increased chance of developing chronic bronchitis.

Oral Health: Smoking can lead to tooth loss, tooth staining, gum disease which may increase the risk of tooth decay.

Cancer: Smoking for a long time also causes cancer to various body organs.

When it comes to a health insurance policy, an insurance company considers the magnitude of illnesses and deaths caused due to smoking and that’s why, smokers need to pay higher premiums to avail health insurance cover. Typically, the insurance companies charge around 15 to 20 percent higher from a smoker policyholder. Those who smoke would need to undergo additional medical checks, before the insurer issues you the policy.

Let’s understand the difference of premium between a smoker and non-smoker individual.

Ritesh (non-smoker) at 30 years of age buys an individual health plan with Rs 5 Lacs coverage, for 1 year policy term, the chargeable annual premium amount is Rs 4,656. However, Raj (smoker) is buying an individual health plan, he is charged with an annual premium amount of Rs 7,552. An increase in premium amount is only due to the fact that Ansh lies in the smoker category of premium. We can see Raj is paying Rs 2896 extra on account of smoking.

Smoker with Existing Health Problems

If you are a frequent smoker that has caused the symptoms of the declining health condition and getting puzzled whether you can get a health insurance. The answer is yes, the only thing required is to make honest and proper disclosures.

The insurance company will then assess the risk associated with your profile and then decide on terms & conditions and the premium to be charged for providing you a health cover. The premiums charged will be higher and a waiting period will be applied for covering your pre-existing diseases. Moreover, if you are seeking an immediate coverage on your deteriorating health condition, you may go for a critical illness policy.

Conclusion:

Smoking makes an adverse impact on your health and your health insurance policy as well. An insurance company will charge you a higher premium in proportion to the risk associated in providing a health cover. An important point to note that you should disclose all relevant information regarding your health and smoking habits. In case, you are found hiding or providing fake information, the insurance company may decline in settling the claims.

Buy health insurance policy and plans in India: Online health insurance plans compare and get best policy. Free comparison medical insurance and mediclaim policy.

Florida Health Insurance Rate Hikes and Quotes

Florida Health Insurance Rate Hike

Florida Health insurance premiums have touched new heights! Every Floridian has the common knowledge that most annual health insurance contracts will endure a rate increase at the end of the year. This trend is not new and should be expected. Every time this issue pops up it seems as though the blame game starts. Floridians blame Health insurance companies; Health insurance companies blame Hospitals, Doctors and other medical care providers, Medical care providers blame inflation and politicians, well, we really don’t know what they do to help the issue… No one seems to be interested in finding the real cause of the health insurance premium rate increase. Most individuals, self employed, and small business owners have taken Florida Health Insurance Rate Hikes as the inevitable evil.

Hard Facts

What are various reports telling us? Why do Health insurance premium have annual rate increases?

Rate of inflation and heath insurance premium rate increase.

America’s health expenditure in the year 2004 has increased dramatically, it has increased more than three time the inflation rate. In this year the inflation rate was around 2.5% while the national health expenses were around 7.9%. The employer health insurance or group health insurance premium had increased approximately 7.8% in the year 2006, which is almost double the rate of inflation. In short, last year in 2006, the annual premiums of group health plan sponsored by an employer was around $4,250 for a single premium plan, while the average family premium was around $ 11,250 per year. This indicates that in the year 2006 the employer sponsored health insurance premium increased 7.7 percent. Taking the biggest hit were small businesses that had 0-24 employees. There health insurance premiums increased by nearly 10.4%

Employees are also not spared, in the year 2006 the employee also had to pay around $ 3,000 more in their contribution to employer’s sponsored health insurance plan in comparison to the previous year, 2005. Rate hikes have been in existence since the “Florida Health Insurance” plan started. In covering an entire family of four, a person will experience an increase in premium rate at every annual renewal. If they would have kept the record of their health insurance premium payments they will find that they are now paying around $ 1,100 more than they paid in the year 2000 for the same coverage and with the same company. The same item was found by the Health Research Educational Trust and the Kaiser Family Foundation in their survey report of the year 2000. They found out that the premiums of health insurance that is sponsored by the employer increases by around 4 times than the employee’s salary. This report also stated that since 2000 the contribution of employees in group health insurance sponsored by employer was increased by more than 143 percent.

One business man predicts that if nothing is done and the Health insurance premiums keep increasing that in the year 2008, the amount of health premium contribution to employer will surpass their profit. Professionals within and outside the field of Florida health insurance, think that the reason for increase in Florida health insurance premium rates are due to many factors, such as high administration expenditure, inflation, poor or bad management, increase in the cost of medical care, waste etc.

Florida health insurance rate hikes affect whom?

Rising rates of Florida health insurance generally affects most of the Floridians who live in our beautiful state. The highest affected individudals are the minimum wage and low wage workers. Recent drops in the renewal of health insurance are mostly from this low income group. They just can’t afford the high premiums of Florida health insurance. They are in the situation where they can not afford the medical care and they can not afford the medical insurance premiums that are assosiated with adequate coverage. Almost half of all Americans are of the opinion that they are more worried about the high health insurance rate and high cost of health care, over any other bill they have on a monthly basis. A survey also finds that around 42% of Americans can not afford the high cost of health care services. There is one very interesting study conducted by Harvard University researchers. They found out that 68% of people who filed bankruptcy covered themselves and their family by health insurance. Average out-of-pocket deductibles for people filed bankruptcy were around $ 12,000 per year. They also found some co-relation between medical expenditure and bankruptcy. A national survey also reports that main reason for people not to take health insurance is the high premium rate of health insurance.

How to reduce Florida’s high health insurance cost? Nobody knows for sure. There are different opinions and experts are not agreeing with each other. Health professionals believe that if we can raise the number of healthy people by improving the lifestyle and regular exercise, good diets etc. than naturally they will need less medical care services which decreases the demands of health care and hence the cost.( This year in Florida the smoking rate has increased by 21.7 percent) One Floridian sarcastically suggested that there are ‘highs’ and ‘lows’ in health care that are needed to reversed. That the state of Florida is to ‘high’ in cost of medical care compare to other States and ‘low’ in the quality of health care.

Florida Health insurance rate hike has attracted many frauds. These frauds float many bogus insurance companies and offer cheap health insurance rate which attract many people to them. These companies usually through assosiations that are based in other states.

Meanwhile reputable Florida health insurance companies provide different types of health insurance like employer sponsored group health insurance, small business health insurance, individual health insurance etc. to vast number of employees and their families. Still there are many people in Florida that lack any health coverage. Today the employer also has found it challenging to decide how to offer employer sponsored group health insurance to their employees, so that both of them arrive at some point of agreement.

Health Savings Accounts – An American Innovation in Health Insurance

INTRODUCTON – The term “health insurance” is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government. Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits” and “medical insurance.” In a more technical sense, the term is used to describe any form of insurance that provides protection against injury or illness.

In America, the health insurance industry has changed rapidly during the last few decades. In the 1970′s most people who had health insurance had indemnity insurance. Indemnity insurance is often called fee-forservice. It is the traditional health insurance in which the medical provider (usually a doctor or hospital) is paid a fee for each service provided to the patient covered under the policy. An important category associated with the indemnity plans is that of consumer driven health care (CDHC). Consumer-directed health plans allow individuals and families to have greater control over their health care, including when and how they access care, what types of care they receive and how much they spend on health care services.

These plans are however associated with higher deductibles that the insured have to pay from their pocket before they can claim insurance money. Consumer driven health care plans include Health Reimbursement Plans (HRAs), Flexible Spending Accounts (FSAs), high deductible health plans (HDHps), Archer Medical Savings Accounts (MSAs) and Health Savings Accounts (HSAs). Of these, the Health Savings Accounts are the most recent and they have witnessed rapid growth during the last decade.

WHAT IS A HEALTH SAVINGS ACCOUNT?

A Health Savings Account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States. The funds contributed to the account are not subject to federal income tax at the time of deposit. These may be used to pay for qualified medical expenses at any time without federal tax liability.

Another feature is that the funds contributed to Health Savings Account roll over and accumulate year over year if not spent. These can be withdrawn by the employees at the time of retirement without any tax liabilities. Withdrawals for qualified expenses and interest earned are also not subject to federal income taxes. According to the U.S. Treasury Office, ‘A Health Savings Account is an alternative to traditional health insurance; it is a savings product that offers a different way for consumers to pay for their health care.

HSA’s enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.’ Thus the Health Savings Account is an effort to increase the efficiency of the American health care system and to encourage people to be more responsible and prudent towards their health care needs. It falls in the category of consumer driven health care plans.

Origin of Health Savings Account

The Health Savings Account was established under the Medicare Prescription Drug, Improvement, and Modernization Act passed by the U.S. Congress in June 2003, by the Senate in July 2003 and signed by President Bush on December 8, 2003.

Eligibility -

The following individuals are eligible to open a Health Savings Account -

- Those who are covered by a High Deductible Health Plan (HDHP).
- Those not covered by other health insurance plans.
- Those not enrolled in Medicare4.

Also there are no income limits on who may contribute to an HAS and there is no requirement of having earned income to contribute to an HAS. However HAS’s can’t be set up by those who are dependent on someone else’s tax return. Also HSA’s cannot be set up independently by children.

What is a High Deductible Health plan (HDHP)?

Enrollment in a High Deductible Health Plan (HDHP) is a necessary qualification for anyone wishing to open a Health Savings Account. In fact the HDHPs got a boost by the Medicare Modernization Act which introduced the HSAs. A High Deductible Health Plan is a health insurance plan which has a certain deductible threshold. This limit must be crossed before the insured person can claim insurance money. It does not cover first dollar medical expenses. So an individual has to himself pay the initial expenses that are called out-of-pocket costs.

In a number of HDHPs costs of immunization and preventive health care are excluded from the deductible which means that the individual is reimbursed for them. HDHPs can be taken both by individuals (self employed as well as employed) and employers. In 2008, HDHPs are being offered by insurance companies in America with deductibles ranging from a minimum of $1,100 for Self and $2,200 for Self and Family coverage. The maximum amount out-of-pocket limits for HDHPs is $5,600 for self and $11,200 for Self and Family enrollment. These deductible limits are called IRS limits as they are set by the Internal Revenue Service (IRS). In HDHPs the relation between the deductibles and the premium paid by the insured is inversely propotional i.e. higher the deductible, lower the premium and vice versa. The major purported advantages of HDHPs are that they will a) lower health care costs by causing patients to be more cost-conscious, and b) make insurance premiums more affordable for the uninsured. The logic is that when the patients are fully covered (i.e. have health plans with low deductibles), they tend to be less health conscious and also less cost conscious when going for treatment.

Opening a Health Savings Account

An individual can sign up for HSAs with banks, credit unions, insurance companies and other approved companies. However not all insurance companies offer HSAqualified health insurance plans so it is important to use an insurance company that offers this type of qualified insurance plan. The employer may also set up a plan for the employees. However, the account is always owned by the individual. Direct online enrollment in HSA-qualified health insurance is available in all states except Hawaii, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Vermont and Washington.

Contributions to the Health Savings Account

Contributions to HSAs can be made by an individual who owns the account, by an employer or by any other person. When made by the employer, the contribution is not included in the income of the employee. When made by an employee, it is treated as exempted from federal tax. For 2008, the maximum amount that can be contributed (and deducted) to an HSA from all sources is:
$2,900 (self-only coverage)
$5,800 (family coverage)

These limits are set by the U.S. Congress through statutes and they are indexed annually for inflation. For individuals above 55 years of age, there is a special catch up provision that allows them to deposit additional $800 for 2008 and $900 for 2009. The actual maximum amount an individual can contribute also depends on the number of months he is covered by an HDHP (pro-rated basis) as of the first day of a month. For eg If you have family HDHP coverage from January 1,2008 until June 30, 2008, then cease having HDHP coverage, you are allowed an HSA contribution of 6/12 of $5,800, or $2,900 for 2008. If you have family HDHP coverage from January 1,2008 until June 30, 2008, and have self-only HDHP coverage from July 1, 2008 to December 31, 2008, you are allowed an HSA contribution of 6/12 x $5,800 plus 6/12 of $2,900, or $4,350 for 2008. If an individual opens an HDHP on the first day of a month, then he can contribute to HSA on the first day itself. However, if he/she opens an account on any other day than the first, then he can contribute to the HSA from the next month onwards. Contributions can be made as late as April 15 of the following year. Contributions to the HSA in excess of the contribution limits must be withdrawn by the individual or be subject to an excise tax. The individual must pay income tax on the excess withdrawn amount.

Contributions by the Employer

The employer can make contributions to the employee’s HAS account under a salary reduction plan known as Section 125 plan. It is also called a cafeteria plan. The contributions made under the cafeteria plan are made on a pre-tax basis i.e. they are excluded from the employee’s income. The employer must make the contribution on a comparable basis. Comparable contributions are contributions to all HSAs of an employer which are 1) the same amount or 2) the same percentage of the annual deductible. However, part time employees who work for less than 30 hours a week can be treated separately. The employer can also categorize employees into those who opt for self coverage only and those who opt for a family coverage. The employer can automatically make contributions to the HSAs on the behalf of the employee unless the employee specifically chooses not to have such contributions by the employer.

Withdrawals from the HSAs

The HSA is owned by the employee and he/she can make qualified expenses from it whenever required. He/She also decides how much to contribute to it, how much to withdraw for qualified expenses, which company will hold the account and what type of investments will be made to grow the account. Another feature is that the funds remain in the account and role over from year to year. There are no use it or lose it rules. The HSA participants do not have to obtain advance approval from their HSA trustee or their medical insurer to withdraw funds, and the funds are not subject to income taxation if made for ‘qualified medical expenses’. Qualified medical expenses include costs for services and items covered by the health plan but subject to cost sharing such as a deductible and coinsurance, or co-payments, as well as many other expenses not covered under medical plans, such as dental, vision and chiropractic care; durable medical equipment such as eyeglasses and hearing aids; and transportation expenses related to medical care. Nonprescription, over-the-counter medications are also eligible. However, qualified medical expense must be incurred on or after the HSA was established.

Tax free distributions can be taken from the HSA for the qualified medical expenses of the person covered by the HDHP, the spouse (even if not covered) of the individual and any dependent (even if not covered) of the individual.12 The HSA account can also be used to pay previous year’s qualified expenses subject to the condition that those expenses were incurred after the HSA was set up. The individual must preserve the receipts for expenses met from the HSA as they may be needed to prove that the withdrawals from the HSA were made for qualified medical expenses and not otherwise used. Also the individual may have to produce the receipts before the insurance company to prove that the deductible limit was met. If a withdrawal is made for unqualified medical expenses, then the amount withdrawn is considered taxable (it is added to the individuals income) and is also subject to an additional 10 percent penalty. Normally the money also cannot be used for paying medical insurance premiums. However, in certain circumstances, exceptions are allowed.

These are -

1) to pay for any health plan coverage while receiving federal or state unemployment benefits.
2) COBRA continuation coverage after leaving employment with a company that offers health insurance coverage.
3) Qualified long-term care insurance.
4) Medicare premiums and out-of-pocket expenses, including deductibles, co-pays, and coinsurance for: Part A (hospital and inpatient services), Part B (physician and outpatient services), Part C (Medicare HMO and PPO plans) and Part D (prescription drugs).

However, if an individual dies, becomes disabled or reaches the age of 65, then withdrawals from the Health Savings Account are considered exempted from income tax and additional 10 percent penalty irrespective of the purpose for which those withdrawals are made. There are different methods through which funds can be withdrawn from the HSAs. Some HSAs provide account holders with debit cards, some with cheques and some have options for a reimbursement process similar to medical insurance.

Growth of HSAs

Ever since the Health Savings Accounts came into being in January 2004, there has been a phenomenal growth in their numbers. From around 1 million enrollees in March 2005, the number has grown to 6.1 million enrollees in January 2008.14 This represents an increase of 1.6 million since January 2007, 2.9 million since January 2006 and 5.1 million since March 2005. This growth has been visible across all segments. However, the growth in large groups and small groups has been much higher than in the individual category. According to the projections made by the U.S. Treasury Department, the number of HSA policy holders will increase to 14 million by 2010. These 14 million policies will provide cover to 25 to 30 million U.S. citizens.

In the Individual Market, 1.5 million people were covered by HSA/HDHPs purchased as on January 2008. Based on the number of covered lives, 27 percent of newly purchased individual policies (defined as those purchased during the most recent full month or quarter) were enrolled in HSA/HDHP coverage. In the small group market, enrollment stood at 1.8 million as of January 2008. In this group 31 percent of all new enrollments were in the HSA/HDHP category. The large group category had the largest enrollment with 2.8 million enrollees as of January 2008. In this category, six percent of all new enrollments were in the HSA/HDHP category.

Benefits of HSAs

The proponents of HSAs envisage a number of benefits from them. First and foremost it is believed that as they have a high deductible threshold, the insured will be more health conscious. Also they will be more cost conscious. The high deductibles will encourage people to be more careful about their health and health care expenses and will make them shop for bargains and be more vigilant against excesses in the health care industry. This, it is believed, will reduce the growing cost of health care and increase the efficiency of the health care system in the United States. HSA-eligible plans typically provide enrollee decision support tools that include, to some extent, information on the cost of health care services and the quality of health care providers. Experts suggest that reliable information about the cost of particular health care services and the quality of specific health care providers would help enrollees become more actively engaged in making health care purchasing decisions. These tools may be provided by health insurance carriers to all health insurance plan enrollees, but are likely to be more important to enrollees of HSA-eligible plans who have a greater financial incentive to make informed decisions about the quality and costs of health care providers and services.

It is believed that lower premiums associated with HSAs/HDHPs will enable more people to enroll for medical insurance. This will mean that lower income groups who do not have access to medicare will be able to open HSAs. No doubt higher deductibles are associated with HSA eligible HDHPs, but it is estimated that tax savings under HSAs and lower premiums will make them less expensive than other insurance plans. The funds put in the HSA can be rolled over from year to year. There are no use it or lose it rules. This leads to a growth in savings of the account holder. The funds can be accumulated tax free for future medical expenses if the holder so desires. Also the savings in the HSA can be grown through investments.

The nature of such investments is decided by the insured. The earnings on savings in the HSA are also exempt from income tax. The holder can withdraw his savings in the HSA after turning 65 years old without paying any taxes or penalties. The account holder has complete control over his/her account. He/She is the owner of the account right from its inception. A person can withdraw money as and when required without any gatekeeper. Also the owner decides how much to put in his/her account, how much to spend and how much to save for the future. The HSAs are portable in nature. This means that if the holder changes his/her job, becomes unemployed or moves to another location, he/she can still retain the account.

Also if the account holder so desires he can transfer his Health Saving Account from one managing agency to another. Thus portability is an advantage of HSAs. Another advantage is that most HSA plans provide first-dollar coverage for preventive care. This is true of virtually all HSA plans offered by large employers and over 95% of the plans offered by small employers. It was also true of over half (59%) of the plans which were purchased by individuals.

All of the plans offering first-dollar preventive care benefits included annual physicals, immunizations, well-baby and wellchild care, mammograms and Pap tests; 90% included prostate cancer screenings and 80% included colon cancer screenings. Some analysts believe that HSAs are more beneficial for the young and healthy as they do not have to pay frequent out of pocket costs. On the other hand, they have to pay lower premiums for HDHPs which help them meet unforeseen contingencies.

Health Savings Accounts are also advantageous for the employers. The benefits of choosing a health Savings Account over a traditional health insurance plan can directly affect the bottom line of an employer’s benefit budget. For instance Health Savings Accounts are dependent on a high deductible insurance policy, which lowers the premiums of the employee’s plan. Also all contributions to the Health Savings Account are pre-tax, thus lowering the gross payroll and reducing the amount of taxes the employer must pay.

Criticism of HSAs

The opponents of Health Savings Accounts contend that they would do more harm than good to America’s health insurance system. Some consumer organizations, such as Consumers Union, and many medical organizations, such as the American Public Health Association, have rejected HSAs because, in their opinion, they benefit only healthy, younger people and make the health care system more expensive for everyone else. According to Stanford economist Victor Fuchs, “The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance.

Some others believe that HSAs remove healthy people from the insurance pool and it makes premiums rise for everyone left. HSAs encourage people to look out for themselves more and spread the risk around less. Another concern is that the money people save in HSAs will be inadequate. Some people believe that HSAs do not allow for enough savings to cover costs. Even the person who contributes the maximum and never takes any money out would not be able to cover health care costs in retirement if inflation continues in the health care industry.

Opponents of HSAs, also include distinguished figures like state Insurance Commissioner John Garamendi, who called them a “dangerous prescription” that will destabilize the health insurance marketplace and make things even worse for the uninsured. Another criticism is that they benefit the rich more than the poor. Those who earn more will be able to get bigger tax breaks than those who earn less. Critics point out that higher deductibles along with insurance premiums will take away a large share of the earnings of the low income groups. Also lower income groups will not benefit substantially from tax breaks as they are already paying little or no taxes. On the other hand tax breaks on savings in HSAs and on further income from those HSA savings will cost billions of dollars of tax money to the exchequer.

The Treasury Department has estimated HSAs would cost the government $156 billion over a decade. Critics say that this could rise substantially. Several surveys have been conducted regarding the efficacy of the HSAs and some have found that the account holders are not particularly satisfied with the HSA scheme and many are even ignorant about the working of the HSAs. One such survey conducted in 2007 of American employees by the human resources consulting firm Towers Perrin showed satisfaction with account based health plans (ABHPs) was low. People were not happy with them in general compared with people with more traditional health care. Respondants said they were not comfortable with the risk and did not understand how it works.

According to the Commonwealth Fund, early experience with HAS eligible high-deductible health plans reveals low satisfaction, high out of- pocket costs, and cost-related access problems. Another survey conducted with the Employee Benefits Research Institute found that people enrolled in HSA-eligible high-deductible health plans were much less satisfied with many aspects of their health care than adults in more comprehensive plans People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes. The survey also found that adults in high-deductible health plans are far more likely to delay or avoid getting needed care, or to skip medications, because of the cost. Problems are particularly pronounced among those with poorer health or lower incomes.

Political leaders have also been vocal about their criticism of the HSAs. Congressman John Conyers, Jr. issued the following statement criticizing the HSAs “The President’s health care plan is not about covering the uninsured, making health insurance affordable, or even driving down the cost of health care. Its real purpose is to make it easier for businesses to dump their health insurance burden onto workers, give tax breaks to the wealthy, and boost the profits of banks and financial brokers. The health care policies concocted at the behest of special interests do nothing to help the average American. In many cases, they can make health care even more inaccessible.” In fact a report of the U.S. governments Accountability office, published on April 1, 2008 says that the rate of enrollment in the HSAs is greater for higher income individuals than for lower income ones.

A study titled “Health Savings Accounts and High Deductible Health Plans: Are They an Option for Low-Income Families? By Catherine Hoffman and Jennifer Tolbert which was sponsored by the Kaiser Family Foundation reported the following key findings regarding the HSAs:

a) Premiums for HSA-qualified health plans may be lower than for traditional insurance, but these plans shift more of the financial risk to individuals and families through higher deductibles.
b) Premiums and out-of-pocket costs for HSA-qualified health plans would consume a substantial portion of a low-income family’s budget.
c) Most low-income individuals and families do not face high enough tax liability to benefit in a significant way from tax deductions associated with HSAs.
d) People with chronic conditions, disabilities, and others with high cost medical needs may face even greater out-of-pocket costs under HSA-qualified health plans.
e) Cost-sharing reduces the use of health care, especially primary and preventive services, and low-income individuals and those who are sicker are particularly sensitive to cost-sharing increases.
f) Health savings accounts and high deductible plans are unlikely to substantially increase health insurance coverage among the uninsured.

Choosing a Health Plan

Despite the advantages offered by the HSA, it may not be suitable for everyone. While choosing an insurance plan, an individual must consider the following factors:

1. The premiums to be paid.
2. Coverage/benefits available under the scheme.
3. Various exclusions and limitations.
4. Portability.
5. Out-of-pocket costs like coinsurance, co-pays, and deductibles.
6. Access to doctors, hospitals, and other providers.
7. How much and sometimes how one pays for care.
8. Any existing health issue or physical disability.
9. Type of tax savings available.

The plan you choose should according to your requirements and financial ability.