Pomerantz Haudek Block Grossman & Gross LLP ("PHBG&G")

SPD's for FEHB

Federal Employees Health Benefits Program
-FEHB Plan Brochures

Links to Plan Brochures for 2003

Links to Plan Brochures for 2004

Links to the FEHB Open Season for 2005 Brochures

Federal Employees Health Benefits Program

FEHB HANDBOOK

Kaiser statehealthfacts.org

TRICARE Handbook


TRICARE Manuals

50% Savings - Healthcare Crisis Turnaround
for Employers, Insurers & TPA's

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

US Supreme Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21, 2003

"This Is Not Some Wild Theory"

"Cut 50 percent of the cost of health care"

US companies mad as hell at HMO premiums
Are All Consultants Corrupt? (Fast Company)

Evolving Role of Third Party Administrators Brings
New Demands and Innovations (Employee Benefit News)
 

Why "Zhou's Model of Prudent Health Care"???

National labor and economical security are being harmed every day by our healthcare crisis when we all have been fantasizing practical solutions from political Hollywood and self-destructive Disneyland. Now it's time to do some reality check:

U.S. Firms Losing Health Care Battle, GM Chairman Says (The Washington Post; one-time registration required)

Excerpt: "American manufacturers are losing their ability to compete in the global marketplace in large measure because of the crushing burden of health care costs, General Motors Corp. chairman and chief executive G. Richard Wagoner Jr. said yesterday as he called on corporate and government leaders to find 'some serious medicine' for the nation's ailing health system. In a speech at the Economic Club of Chicago, the auto executive, who is responsible for providing health insurance for ...."

Health costs a big part of GDP (Newsday.com) February 9, 2005

No Cure Seen for Growth in Employers' Health Costs (12/02/2004, The New York Times; one-time registration required)

Excerpt: "The growth in health care spending by private employers slowed in recent years, creating some optimism that the employers had turned the corner in their struggle with rising costs. But any relief appears to have been short lived, according to a study to be released today. Growth in spending in the first half of 2004 was about the same as it was in 2003, according to the Center for Studying Health System Change, a nonprofit research group in Washington that tracks spending levels."

Tracking Health Care Costs: Spending Growth Slowdown Stalls in First Half of 2004 (Center for Studying Health System Change)

Report (PDF) (Employee Benefit Research Institute)

Excerpt: "The recent slowdown in health care spending growth stalled in the first half of 2004 as health care costs per privately insured American increased 7.5 percent--virtually the same rate of increase as in 2003. Private-sector spending on health care constitutes more than one-half of all health care spending, and both the private and public sectors are subject to similar cost pressures.1 Growth in spending on hospital inpatient care slowed to 5.1 percent in the first half of 2004, ...."

Health Premiums Are Rising As You Read This According to Council of Insurance Agents & Brokers (The Adviser via BenefitNews.com)

Excerpt: "A broker group has found that health insurance premiums are rising by double-digit percentages even over the course of the plan year. In a recently released study (http://www.ciab.com/ContentManagement/ContentDisplay.cfm?), researchers ... reported that companies of all sizes, from those with 50 or fewer employees to those with more than 500, found their premiums were 10% to 20% higher over the last six months than they were at the beginning of the year."

Medical Cost Reference Guide (PDF) (Blue Cross Blue Shield Association)

76 pages; October 2004 revision. Excerpt: "A comprehensive collection of healthcare cost data addressing the critically important national issue -- access to affordable healthcare.... [W]e are happy to be releasing our third annual Medical Cost Reference Guide, which brings together some of the best secondary research available on the key drivers of healthcare costs."

BLS Report on Employer Costs for Employee Compensation - September 2004 (U.S. Bureau of Labor Statistics)

Excerpt: "Employer costs for employee compensation averaged $25.36 per hour worked in September 2004, the U.S. Department of Labor's Bureau of Labor Statistics reported today. Wages and salaries, which averaged $17.96, accounted for 70.8 percent of these costs, while benefits, which averaged $7.40, accounted for the remaining 29.2 percent."

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

"Zhou's Model of Prudent Health Care"

Ford Motor Co. Chief Executive Officer Bill Ford has assigned one of his top executives, Vice Chairman Allan Gilmour, to craft a proposal for fixing the nation's health care system. On December 2, 2003 he said: "But I do think we need a new model, because if the employers are getting choked with health care, and the hospitals are all losing money and the HMOs claim they're not making any money, then the system does not seem to be working very well".

Automotive Industry Threatened by Rising Health Insurance Costs According to William Ford, Jr. (CBSMarketWatch via Interactive Investor)

 

Excerpt: "Rapidly rising health-care costs have become an albatross weighing down the automotive industry, William Ford Jr., chief executive officer of Ford Motor, told industry executives Wednesday. Despite cutting costs by billions of dollars over the past few years, Ford Motor's medical liabilities are threatening its fiscal health .... .... 'In 2000, we paid $2 billion for employee health care,' Ford told the ... U.S. Chamber of Commerce. 'In 2003, those costs rose to $3.2 billion.'"

Health Insurers Getting Bigger Cut of Medical Dollars (Investor's Business Daily: Breaking News)

"The market is easy pickings for insurers, said Uwe Reinhardt, a health-care economist at Princeton University. He says companies are reluctant to haggle with their carriers.

"You could say it's their DNA, but it's not. It's the way they're structured. There's no push-back," Reinhardt said.

"You can stick any bill under their nose and they would pay it."

One Nation under Debt: U..S. economy threatened by aging of America

"The long-term economic health of the United States is threatened by $53 trillion in government debts and liabilities that start to come due in four years when baby boomers begin to retire. (Related graphic: U.S. economy threatened by aging of America).....

 

Comptroller General David Walker, the government's chief accountant, travels the nation warning of the impending crisis. "I am desperately trying to get people to understand the significance of this for our country, our children, our grandchildren," Walker says. "How this is resolved could affect not only our economic security but our national security. We're heading to a future where we'll have to double federal taxes or cut federal spending by 50%."

"I just think that as a country, if we have a model that isn't working and a model that's driving jobs overseas, then we'd better take another look at it," Ford said.

Gary Cowger, president of GM's North American operations, urges speedy overhaul of U.S. health care (Forbes.com). He called for an overhaul of the U.S. health care system on Jan. 30, 2004, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector.

GM to Report $60B in Future Health-Care Obligations (Quicken.com - News Center:)

Rising Cost of Health Benefits Cited as Factor in Slump of Jobs (The New York Times)

Law As An Agent of Health System Change - [Abstract] [Full Text] [PDF]

(Health Affairs), March/April 2004; 23(2): 29-42.

Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging"
(Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004)

Life and Health Insurers' Profits Skyrocket 213% in First Quarter 2004, Highest Increase in Decade, According to Weiss Ratings (BUSINESS WIRE)--Sept. 22, 2004

HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue Shield Plans Report 63% Jump in Earnings (BUSINESS WIRE)--Aug. 30, 2004

A.M. Best Special Report: Moderating Costs Favorably Impact Health Insurers' Earnings

Business Insurance - Health cost moderation boosts insurer profits: Best (Jan. 17, 2005)

Forbes.com: Ford urges "national solution" to U.S. health care (Reuters, 04.07.04)

"DETROIT (Reuters) - Ford Motor Co. called for a "national solution" to the problem-plagued U.S. health system Wednesday, saying drug companies were the only ones happy with the status quo.

Ford Vice Chairman Allan Gilmour was the latest U.S. auto industry official to sound the alarm about health care, amid warnings that mushrooming medical costs threaten the very survival of the nation's embattled manufacturing sector."

National Survey Shows Half of Employers Want Feds to Do Health Care System Overhaul (The San Diego Union-Tribune)

Excerpt: "Half of all employers believe the federal government should significantly overhaul or even scrap the nation's privately financed health care system, according to a new survey. Just over a third of all employers – 36 percent – believe the government should enact significant reforms to address the rising cost of health care, while 14 percent say health care should be nationalized into a federally financed system like Medicare."

Local Impact of GM Job Cut Plans (wlns.com)

"1/10/05- General Motors announces plans to reduce its US workforce by nearly 7% in 2005.  That means about 8,000 hourly and salaried positions at GM will be eliminated through attrition and retirement over the next 12 months."

What Kind of New Model for Speedy Overhaul
of U.S. Healthcare
Do We REALLY Need?

Points & Things Must Be Considered But Ignored By Most:

1. Eliminating the need of universal one payer system to protect employer based healthcare system in order to make it practically working;

2. Minimizing, if not completely eliminating, the need of multimillion dollar punitive damages to deter reckless claim practice;

3. Reducing both claim administrative costs for health-care plans and healthcare administrative costs for health-care providers;

4. Improving US healthcare quality through eliminating health care medical inflation and truly separating medical decision-making from business profit decision-making;

5. Reducing the number of frivolous lawsuits by all parties for health insurance and medical malpractice/tort actions;

6. Promoting the consistent treatment of claimants solely based on ERISA law and the plan SPD;

7. Providing a nonadversarial method of claims settlement through ERISA claim education and ERISA appeal practice for all involved;

8. Minimizing the cost of claims settlement for all concerned and involved solely based on ERISA law and specific ERISA plan provisions instead of third-party managed-care contracts and profit-making guidelines;

9. Enhancing the ability of plan sponsors and trustees of healthcare benefit plans to manage their funds expertly and efficiently by preventing premature and costly judicial intervention in their decision-making processes;

10. Enhancing the ability of plan sponsors and trustees of healthcare benefit plans to correct their errors or omissions, or at the same time, an opportunity to convince a disgruntled or disappointed claimant (patient and healthcare provider) that he or she is incorrect based on federal law and the plan provisions;

11. Enhancing the ability of plan sponsors and trustees to interpret health-care plan provisions of individual plan SPD instead of non-applicable and non- controlling third-party managed-care contracts and profit-making guidelines; and

12. Helping assemble a factual records of healthcare medical decision-making and plan benefits decision-making that will assist a court in reviewing the fiduciaries actions and possible medical malpractice actions.

Zhou's Model of Prudent Health Care Will Revive Employer-based Healthcare System:

"Zhou's Model of Prudent Health Care"
Are All Consultants Corrupt? (Fast Company)

MSNBC - Employers see health care premiums up 17% in 2004

Aon Forecast: Rise in Medical Plan Trend Rates to Taper Off Slightly, But Double-digit Increases Will Continue in 2004

"According to Aon Consulting's Spring 2004 Health Care Trend Survey, employers can expect more of the same: double-digit increases for all types of medical coverage, with HMOs and POS plans forecast to increase at 14.1 percent."

Benefit Spending Drives Compensation Costs (BenefitNews.com)

Employer Costs for Employee Compensation--December 2003 02/26/2004 (Bureau of Labor Statistics)

Mass layoffs up in January 2004 (Bureau of Labor Statistics)

Ford said he has no preconceived notion of how to solve the health care crisis.

Cowger proposed no solution to the health care problem in a speech to an international automotive conference sponsored by J.D. Power and Associates, an influential industry research firm.

This is the exact new model what Ford Motor, GM and U. S. employers are looking for:

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

"Zhou's Model of Prudent Health Care"

1. Cut 50 percent of the cost of health care for your company and improve health care service access and qualities at the same time;

2. Cut 50% of the cost of employee benefits administration and improve the quality of benefits management and satisfaction of employees;

3. Cut, fundamentally and voluntarily, 50% of the cost of health care by providers through unprecedented teamwork with health care providers, employees, employers and TPA's by ERISA claim procedure compliance;

4. Consulting in ERISA SPD and claim procedure compliance to truly automate health benefits management and cost containment;

5. Educating in ERISA SPD and claim procedure and the strategies for your executives, benefits managers/HR staff, employees and TPAs in truly cutting cost of health care and minimize noncompliance risks;

6. Consulting with ERISA strategies for executives and benefits managers as well as TPA's in ultimate benefits automation and self services.

7. Abandon completely current managed care model and mechanism, create a new national health care model, "Zhou's Model of Prudent Health Care", with fiduciary compliant, doctor-patient and employer-employee trusted care, where the employers completely control plan funding and spending, employees completely control access and quality in health care, physicians completely control healthcare quality, a new model with administration simplicity, complete fiduciary compliance with all applicable federal and state laws, ERISA claim regulation and state utilization and external review laws, with transparency, free choice and free access with prudence, everyone takes his/her own responsibilities.

8. This "Zhou's Model of Prudent Health Care" includes completely new but extremely simple benefits design, compliance and mathematical modules, with ultimate goals of 50% health-care expenditure saving and free access to quality health care by eliminating unnecessary and self-inflicted administrative costs and conflicts as well as managed care crisis.

9. Managed care restricts and limits access to the quality care by someone else other than patients and physicians resulting in consumer's backlash with distrust and stimulating escalated health care costs, while "Zhou's Prudent Health Care Model" will let patients and physicians decide prudently on access and utilization of quality medical care under completely new ERISA compliant, transparent and prudent benefits schedule.

We will help you to strategically and operationally accomplish these goals when conventional and traditional thinking pattern, legislation and industry practices have failed undisputedly in controlling skyrocketing health care costs.

"Discretionary Clause" >> "Discretionary Spending" >> "Discretionary Medical Inflation" >> "Discretionary Insurance Robbery" >> Discretionary Medical Killing >> "Discretionary Universally Uninsured"  >> "Discretionary Jurisdiction Non-enforcement"  >> U.S. Healthcare Crisis!

Licensing of ERISA-Covered Benefit Plan Administrator, New York State Insurance Department, January 26, 2000

Letter opinion per CIC §12921.9 : Discretionary Clauses, (PDF) John Garamendi, Insurance Commissioner, DEPARTMENT OF INSURANCE, STATE OF CALIFORNIA, February 26, 2004

FEATURE-US companies mad as hell at HMO premiums (Forbes - Oct 16, 2003)

GM urges speedy overhaul of U.S. health care (Forbes.com)

"LAS VEGAS, Jan. 30 (Reuters) - General Motors Corp. (nyse: GM - news - people) called for an overhaul of the U.S. health care system on Friday, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector."

"For the first time in nearly 20 years, small businesses say soaring worker health costs, not taxes, are their biggest headache. Taxes had been No. 1 since 1986." (USA Today 4/20/2003)

"The skyrocketing cost of health care is one of the toughest challenges facing Ford Motor Co., Chairman and CEO Bill Ford Jr. said Friday......

The solution to the health care problem will require government and business to work together in a new way, Ford said. " (AP  05/30/2003)

Ford Exec Gets New Task: Solve National Health Care Crisis (Detroit Free Press) (12/03/2003)

GM stocks up ahead of labor talks (MSNBC), Union rejects GE healthcare proposal (CNN), and Chrysler Shifts Additional Benefit Costs to Salaried Retirees (Detroit Free Press via International Foundation of Employee Benefit Plans) while Health care experts are not optimistic (Conroe Courier).

Healthcare Coverage a Growing Issue in Labor Negotiations (Washington Post)

"There's really not very much cost-control going on at all other than employers moving to cost-sharing," as found and concluded by the latest research,  in 12 nationally representative communities from site visits and interviews with healthcare executives, employers and policymakers conducted in 2002 and 2003 by Center for Studying Health System Change (HSC).

No relief for health-care premium sufferers, 50% cost increase expected in 3 years, ...(Chicago Tribune)

HMOs Could Raise Premiums By 18 Percent Next Year (Dow Jones News Wires via St. Louis Post-Dispatch)

Aon, Marsh Forecast Health Cost Increases Above 16% (BenefitNews.com)

What's Your Strategy for Controlling Healthcare Costs? (PDF) (Aon Consulting/Radford Surveys)

43.6 Million People in the United States Lack Health Coverage, Census Bureau Figures Say (KaiserNetwork.org)

Towers Perrin Projects Fifth Consecutive Year of Double-Digit Health Care Cost Increases in 2004

Business Survey Finds Employers Faced with Healthcare Cost Increases Exceeding Ability to Pay (acordia.com)

More Labor Conflicts Expected Over Health Care Costs (AP via SFGate.com)

Cost of Private Health Insurance Lost in National Healthcare Coverage Debate (Los Angeles Times; one-time registration required)

Excerpt: "The rising cost of private health plans "has been like a stepchild to all the other problems," said Len Nichols, a health economist with the nonpartisan Center for Studying Health System Change. "Everyone knows it's there, but no one wants to talk about it."

Insurance Disputes Might Leave Patients Covering More Health Costs (KaiserNetwork.org)

Excerpt: "While in the past, doctors' and hospitals' 'threats' to end contracts with certain health plans mostly amounted to 'negotiation tactic[s],' recently many doctors and hospitals are 'leaving offers on the table' and 'betting that their patients will pick different health plans or pay out-of-pocket for services,' the Chicago Tribune reports."

1/3 of Workers Uninsured in 2001 Were Employed by Large Firms
Full Text of Report (pdf) (The Commonwealth Fund)

Press Release   Summary   Report

Excerpt: "Thirty-two percent of workers lacking health coverage in 2001 were employed by large firms, up from 25% in 1987, a new Commonwealth Fund report finds.... The report, The Growing Share of Uninsured Workers Employed by Large Firms, was coauthored by Sherry Glied, Ph.D., and Sarah Little of Columbia University and Jeanne Lambrew, Ph.D., of George Washington University."

Fewer Employees Have Health Insurance at Large Companies (USA Today)

85 Million Americans Had No Health Insurance At Some Point During Four Year Period Studied (The Commonwealth Fund)

Job-Based Health Insurance in the Balance: Employer Views of Coverage in the Workplace (PDF) (The Commonwealth Fund)

Overview: Managed Care Insurer Liability Among the States (National Conference of State Legislatures)

The Battle Over Benefits (Workforce.com)

Excerpt: "The cost of health care is strangling companies, prompting strikes and leaving an increasing number of Americans without any coverage at all. Some companies are coping, but experts fear that a sick system will have to come close to collapse before there is reform."

Now "employers moving to cost-sharing" as the last hope for U.S. healthcare heart attack resuscitation was given a prognosis of "future federal budget deficits of more than $44.2 trillion, being overwhelmed by the 'baby boom' generation's future healthcare and retirement costs. (CNN 05/29/2003)

Opinion: Health Savings Plans Unlikely to Achieve Lofty Goals (Paul Ginsburg, published by the Center for Health System Change)

As reported by CNN on May 29, 2003, "If the problems aren't corrected, the study shows, the already huge projected shortfall could grow to $54 trillion by 2008 and keep getting larger every year thereafter."

With "Zhou's Model of Prudent Health Care" and our unique and unprecedented expertise and experiences in ERISA and health care consulting, educating and claims recovery, we will prove to you that US health-care crisis, including your company health care crisis, can be fixed if we are truly committed and persistent in preventing and fixing this potentially inevitable health-care crisis triggered national economy ($44 trillion deficit)  and labor crisis in this country.

O'Neill: Health costs can be halved  (post-gazette.com)

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Detroit's Healthcare Crisis--and Ours (Geoffrey Colvin on Fortune.com) will take you to "Pay or Play" Ground if  American business leaders and owners don't act now.

Gettelfinger, Gilmour: Nation must solve health care crisis(Biloxi Sun Herald, MS)

GM urges speedy overhaul of U.S. health care (Forbes.com)

"LAS VEGAS, Jan. 30 (Reuters) - General Motors Corp. (nyse: GM - news - people) called for an overhaul of the U.S. health care system on Friday, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector."

Health-cost surge hurts profits, jobs (Bloomberg News, February 08, 2004)

"Ford Motor Co. Chief Executive Officer Bill Ford, in Chicago last week for the auto show, said health care costs are his biggest challenge.

 

"We are paying more for health care per vehicle than we are paying for steel," he said, adding there is no easy solution.

 

Ford spent $2.8 billion - $700 per vehicle - in 2002 on health care for U.S. employees, retirees and dependents."

Pay or Play Bill in California Won't Work Without Price Controls (The Foundation for Taxpayer and Consumer Rights)

Cost Shifting: New Myths, Old Confusion, and Enduring Reality (Health Affairs)
Excerpt: "Instead of focusing on the symptom of cost shifting, we should be focusing on the causes."

Testimony of Consumers Union on Consumer-Driven Health Care (Consumers Union)

Excerpt: "So-called 'consumer driven' health care plans, which have defining features of high-deductible coverage and (possibly) tax-advantaged employer contributions to health reimbursement or savings accounts, may create serious problems for the U.S. health care system. Consumers Union believes that this coverage is misnamed, misguided from a policy perspective, and a dangerous distraction from the need to solve the health insurance crisis that faces 43.6 million uninsured consumers ..."

Aon's Fall 2003 Health Care Trend Survey (Aon Consulting)

2004 Segal Health Plan Cost Trend Survey (PDF) (The Segal Company)
 

Transit, grocery, law labor unrest roils California (AP)

Kroger strike, Medical cost to blame (wvgazette.com)

Rising Health-Care Costs at Heart of Labor Strife in Southern California (Los Angeles Times; one-time registration required)

From wages to health care, Medical coverage first and last issue in labor contract negotiations, (Sunday Gazette-Mail - Business)

“In labor negotiations now, the first day you talk about health-care coverage, and the last day you talk about health-care coverage,” said Jim Bowen, president of the West Virginia Labor Federation. “It’s the No. 1 issue and the last issue. The costs are spiraling, and health insurance considerations come ahead of everything else.”

Opinion: a Watershed Strike (Kelly Candaele & Peter Dreier in The Nation)

Grocery strike, spiraling health costs are very close to home (SignOnSanDiego.com)

(Jin Zhou, ERISAclaim.com) "Wal-Mart bare-bones benefits strategy and Band-Aid fix and solutions to the U.S. healthcare and labor crisis will temporarily stop "local bleeding" (health care costs per employee 40% less than the U.S. average, Wysocki/Zimmerman, Wall Street Journal, 9/30).for no more than two years and will inevitably result in unintended backslash accelerating employer-sponsored health care benefits system collapsing and labor disasters.

Wal-Mart is nation's number one employer, if 33% of preventable conditions and 60% of hospital admissions become eligible for the catastrophic medical claims for another 27%, 54% of Wal-Mart Associates in two years, everyday low-price logo may not hold the truth." (Jin Zhou, ERISAclaim.com)

Patient Cost Sharing: How Much is Too Much? (Center for Studying Health System Change)

Out-of-Pocket Costs Affect Sicker, Low-Income Workers More, Study Says (KaiserNetwork.org)

JS Online: Workers paying higher health care deductibles

The "number one driver" of health care costs is the amount of health care services employees use, Heaps said. "Discretionary spending is driving us crazy."

This is why:

1. A $1.0 Trillion Nuclear Solution to Our Nation's Health-care Crisis

2. ERISA Demystified for Providers, Insurers, Employers, TPAs, Patients, Regulators and Legislators

3. U.S. healthcare cost spiral seen continuing (Reuters Health via blueshieldca.com)

4. Another main reason for failures in health care costs cutting at this critical time in this country is that strategies and measurements employed so far are mostly against health-care providers, claims submitters, or completely without truly understanding health-care provider's "pain-and-suffering" in managed care claim denials and appeals. We are the ultimate experts in health care provider claim denial and appeals, which makes us the most uniquely qualified and credible experts in 50% health-care costs cutting AFTER other "real experts" exhausted their expertise.

5. "Pioneer" as defined by Webster's Unabridged Dictionary

   "1. a person who is among those who first enter or settle a region, thus opening it for occupation and development by others."

   "2. one who is first or among the earliest in any field of inquiry, enterprise, or progress: pioneers in cancer research."

Fortune.com - Magazine - How to Defang the Health-Care Cost Monster

"All those impulses are understandable. But all involve cost shifts. And in the end, cost shifts aren't about solving the problem; they're about making health costs somebody else's problem, a situation that will always favor those with political power and beggar the little guy.

.....

 

But the first thing that has to change is the national mindset. We can't keep pushing costs to the other guy; we need to reorganize health delivery in ways that cut costs while improving quality. That won't be easy, because every dollar of health-care "waste" is somebody's dollar of income. Still, until we start thinking clearly about our goals, we're just playing make-believe."

Most Large Employers Use Consultants for Benefit Plan Design, Actuarial Work and Vendor Selection (The Adviser)

Excerpt: "Eighty percent of the 408 respondents say they use consultants, most often for their health plans, although 55% employ them for their disability plans as well. Surprisingly,

Excerpt: "Eighty percent of the 408 respondents say they use consultants, most often for their health plans, although 55% employ them for their disability plans as well. Surprisingly, fewer than half call in consulting companies for help with retirement plans, both defined benefit and defined contribution, while 30% use consulting services for flexible benefit plans and 22% for wellness programs."

ERISA FAILURE SYNDROME (EFS) has fundamentally and drastically eroded not only our health-care system, pension and retirement, but also our nation's labor market, US economy, and American dreams as well as American value and security.

Law As An Agent of Health System Change - [Abstract] [Full Text] [PDF]

(Health Affairs), March/April 2004; 23(2): 29-42.

Most importantly, American employers have been mistakenly and detrimentally believing that they have less or no control over healthcare costs for their employees and retirees in today's healthcare market by delegating their power and fate to someone else, in hope that more managed care discounts, employees cost-shifting, canceling retiree's benefits and tax incentives will save and avoid their crisis in healthcare, labor and pension survival. Their "hands free" "ASO" shortcuts and "mind free" ERISA pre-emption privilege in the past decades have brought them double digitals overall healthcare costs explosions and labor strikes!

Are All Consultants Corrupt? (Fast Company)

Excerpt: "That's one possible conclusion in the wake of the Enron scandal. According to David Maister, who's been studying professional-services firms for more than 20 years, it's time to clear the air."

Under ERISA, only American Employers have complete and ultimate control over funding and healthcare price and costs.

As both GM and Ford have seen the "Code Blue" that "mushrooming costs threatened the survival of the country's struggling manufacturing sector", American employers must get out fast from the dead tunnel of managed care and wholeheartedly quit defending and fantasizing the past fatal mistakes and failures in ERISA benefits administration. True leaders must get their minds and hands on employee benefits overhaul through ERISA compliance to cut 50% in costs and expand benefits and coverage at the same time!

Any health care proposals and solutions to current U.S. healthcare, benefits, labor and pension crisis without ERISA compliance and education will backfire with more cost explosions and union strikes, and will threat the survival of the country's struggling economy, labor and pension security.

"Zhou's Model of Prudent Health Care" is an extremely valuable strategy and initiative for a truly outcome oriented overhaul, instead of the popular and current tweaking of the existing failing health care system, should conventional experts and strategies fail, in a tmely fashion, to develop ERISA compliance, costs savings, benefit increases, as well as a quality and safety oriented overhaul for U.S. economic survival.

A speedy strategic vision and mission overhaul for its survival is not to tweak the existing failing and hopeless healthcare system with the existing managed-care model that has created double-digit mushrooming costs and destroyed the faith and trust in our healthcare system, primarily sponsored by American employers, with GM being the No. 1 payer at a price tag of $4.5 billion each year.

The cruel facts and warning intelligence are so clear that nation’s health care survival cannot rely upon the popular and conventional strategies and experts based on the principles of the managed care model by employee burning through cost sharing and shifting, tax incentive blood transfusions and segmental reengineering in disease management and provider contracting strategies.

As proposed in “Zhou’s Model of Prudent Healthcare” solution, any strategy to improve safety, quality and efficiency of the health care system that serves our beneficiaries for American employers, has to be fully compliant with ERISA, rather than the current cosmetic and cursory compliance, by cutting costs and doubling benefits at the same time.

Zhou's Model and strategies are designed to enable and empower employees and beneficiaries to voluntarily, instead of confrontationally, make their health decisions and choices for saving healthcare costs, and to invite healthcare providers to voluntarily provide the best quality of healthcare at a reasonable and minimal expense.

Any strategies, placing employees and beneficiaries and healthcare providers in a confusing or punitive way and a confrontational fashion, as the current managed-care model has been doing, will backfire with detrimental consequences. As health-care benefits sponsored by any American employers are primarily provided to benefit employees for the purpose of retaining the best labor force in the market and rewarding healthcare providers for delivering the quality, safety and perceivable satisfaction of healthcare at reasonable and competitive prices. By reviewing the current managed-care litigation landscape, as outlined and summarized at my website, ERISAclaim.com/Courtwatch.htm, we would all agree that dissatisfactions and confrontation from American workers and healthcare providers are much greater than the perceived and proclaimed success of the current managed-care model.

There are hundreds of thousands of strategies and proposals out there in the market, but they are all conventional and incidental tweaks and symptomatology remission therapy to preserve and defend the current fatal healthcare failure, invented and promoted by conventional experts and professionals in the development of the managed care market and history in the past two decades. “Administrative Service Only” (ASO) contracting and Managed-care “Deep Discounts” have created undisputed overall out-of-control skyrocketing costs under a false promise of managed-care savings resulting in less and less quality and efficiency in the healthcare delivery system. At the same time, $4.5 billion from GM and $1.55 trillion from U.S. have rewarded most efficiently the individuals and industries with the greatest financial success, but left the American worker at the breaking point in the healthcare managed-care environment as well as more and more uninsured American workers.

The “conventional experts and strategies” in creating this managed-care crisis, while disregarding ERISA compliance, shall be the target, instead of the driver, of U.S. Healthcare ERISA overhaul for survival.

ERISA has been poorly understood by American employers in the past 28 years. The ERISA diagnosis and solutions in Zhou’s Model of Prudent Healthcare, as the solution to U.S. Healthcare overhaul, are for a quantum change with a nuclear effect for empowering U.S. employers to truly utilize ERISA to control healthcare costs and benefit U.S. Employees and their families.

We provide educational and consulting solutions to employers/plan sponsors, insurers and TPA's with compliance assistance to reduce  administrative and healthcare costs and risks through compliance of ERISA to fundamentally solve your healthcare crisis and to avoid potential labor crisis and future U.S. budget deficit ($44 trillion deficit).

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What is "Zhou's Model of Prudent Health Care"?

Please e-mail for details  or

Call:  630-736-2974

U.S. Health-care Crisis
& ERISA Criminal Enforcement


ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

ERISAclaim.com:  ERISA Certification Programs
for Cost-Saving & Reimbursement by Compliance

DOL + DOJ Enforcement of ERISA

HHS Works with ERISA (+77 Millions/4 Yrs)

"Cut 50 percent of the cost of health care"

"The latest Harvard & RAND study revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care."

"A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),¹⁰ which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

The updated Harvard & RAND study, funded by the U.S. Department of Labor (DOL), published on June 18, 2003 through Health Affairs reported: "....We found much higher denial rates than those previously reported.....Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was some evidence of this sort of dual expertise being brought to bear on coverage decisions at the two groups we studied."

Testimony of Consumers Union on Consumer-Driven Health Care (Consumers Union)          Click Here for full testimony (PDF format only)

Excerpt: "So-called 'consumer driven' health care plans, which have defining features of high-deductible coverage and (possibly) tax-advantaged employer contributions to health reimbursement or savings accounts, may create serious problems for the U.S. health care system. Consumers Union believes that this coverage is misnamed, misguided from a policy perspective, and a dangerous distraction from the need to solve the health insurance crisis that faces 43.6 million uninsured consumers ..."

U.S. Healthcare Crisis Is Driven By Medical Inflation in Pricing & Costs Stimulated by MCO/PPO/HMO Discount and Capitation While Promoted and Guaranteed By ERISA Failure

HMO & PPO Managed Care Contracting to  Disregard & Substitute ERISA SPD & Claims Procedure Is The Primary & Inevitable Cause of Medical Inflation.

Billllll & Denialllll  =  Billllllllllllllllllll + Denialllllllllllllllllllllllll  =
Billllllllllllllllllllllllllllllllllllllllllll++Deniallllllllllllllllllllllllllllllllllllllllllll =
U.S. healthcare crisis!!!="The Health Care Misery Index"

The cost driving factors are evident in these three cases in the context of ERISA and managed care:

FALLICK v NATIONWIDE MUTL INS

HCA Health Services of Georgia, Inc. v. Employers Health Ins. Co.

McDougall vs Pelchart, et al (Aetna, UPS)

ERISA Failure + "PPO discounts" = "Price Gouging" or Medical Inflation;

Without PPO discount = "dual fee schedule" " insurance fraud";

With PPO discount = "charging more" against uninsured;

Indigent discount for "44 - 82 million uninsured" = "dual fee schedule" insurance fraud;

More PPO discounts/"savings" = more provider's price gouging/inflation;

From PPO's, silent PPO's and incentive HMO's to hospital networks and physician IPA's, price/discount negotiation power wars between managed-care organizations and health-care providers are unfolding more dramatically but invisibly than terror war that are resulting in unprecedented medical inflations.

GAO finds higher health care costs in Milwaukee (AP Wire) 08/23/2004

Full Text of 'Improving Health Care: a Dose of Competition' (PDF) (Federal Trade Commission; Department of Justice)

361 pages, Excerpt: "Conclusion. Remedies are a critical issue in implementing an effective competition policy. If remedies are inadequate, they will not have a credible deterrent effect. If remedies are excessive, they will over-deter, and discourage conduct that is actually permissible. Balancing these considerations is a difficult task." (PAGE 20)

More managed care = more lawsuits and more legislations.

MGMA survey highlights reimbursement disparities (American Medical News)

"Practices reported lower actual payment rates than those contracted for nine of the 10 common CPT codes examined. - Aug. 9"

Health care discounts vary widely (JS Online)

County's audit provides rare look into hidden pricing arrangements

Hearing: A Review of Hospital Billing and Collection Practices

Subcommittee on Oversight and Investigations, June 24, 2004

CLASS ACTION LAWSUITS BY UNINSURED PATIENTS BROUGHT AGAINST SIX MORE NONPROFIT HOSPITAL SYSTEMS AROUND THE COUNTRY - 07/09/04 (hospitalpricegouging.org)

Lawsuit Filed Against National “For-Profit” Hospital Groups To Protect Uninsured Patients From Hospital Price Gouging And Unconscionable Billing Practices - August 5, 2004 (hospitalpricegouging.org)

Proposed class action suit against hospital group filed in Miami (AP Wire | 08/05/2004 )

Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging"
(Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004)

HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue Shield Plans Report 63% Jump in Earnings (BUSINESS WIRE)--Aug. 30, 2004

California Nurses Association: New Study Documents High Markups on Hospital Charges

"OAKLAND, Calif.--(BUSINESS WIRE)--Sept. 8, 2004--New research on pricing practices of over 4,000 hospitals across the U.S. documents that huge markups in charges to patients, especially for prescription drugs, medical supplies, and surgeries, are a major factor in exacerbating the nation's health care crisis and the pricing scandal that has prompted hearings, lawsuits and a growing public outcry.....

 

Overall, the nation's 100 most expensive hospitals marked up their gross charges an average of 673% over their costs -- meaning the average top 100 hospital would bill $673 for a patient's case where the actual costs were $100."

USATODAY.com - Hospital sues insurer for not paying full charge

USATODAY.com - Hospital bills spin out of control

"The debate over hospital charges is part of the fallout from the rise of managed care, when insurers drove down payments to doctors and hospitals with a take-it-or-leave-it attitude. In response, hospitals banded together in systems, giving them larger market share and bargaining power. Many hospitals successfully demanded bigger payments by telling insurers to pay up or they would stop accepting their patients."

 

"We raised charges 45%," Callanan says. "We only collected $8 million more."

While facing unsustainable healthcare crisis and dissatisfied of insurers and TPA/MCO's performance, American employers started their own E-bay style "more discounts" bidding war among their ASO/TPA market, resulting more and deeper discount up to 50-70% PPO discount/"savings", which in turn, must translate into hospital new UCR (list price), "Price Gouging" discovered by Glenn Melnick, Ph.D, presented to Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004.

BE ALERT!

That was then for a set of factors that includes low deductibles of no more than $500 for the most Americans, restraining for providers and hospitals in fears of "dual fee schedule fraud" when giving patient "balance off-setting" discounts.

The new environment starting 2004 with higher deductible of $1,000 from true HDHP under HSA and non-HSA plans and HHS new Indigent Discount policy will set new records of disastrous medical inflation, totally contrary to what HSA is said to promise and what employers have dreamed.

Therefore, U.S. health care failure and crisis can be diagnosed as:

"ERISA Failure" = "Quality Failure" in U.S. Heath Care Crisis;

"Medical Inflation" = "Quantity Failure" in U.S. Health Care Crisis = Managed Care Contracting Discount and "Price Gouging".

"The history will prove that the headline political strategy and current trend in consumer-directed health plans and employee cost-sharing strategies will not be able to stop current US health-care crisis because these strategies and approaches are based on wrong diagnoses of current health-care crisis, without fundamental and etiology solution to the driving force of escalating and worsening health-care costs in billing and charges by health-care providers as a form of survival and revengeful but spiral billings as a result of reckless and noncompliant claim denials. These strategies are simply shifting crisis to the employees and federal government tax program to practically accelerate health costs by temporarily covering up the pain and suffering from the employers and by punishing the very victims of health-care and labor industry: American workers and their families as well as patients. The strategies, however, will alleviate temporarily the employers' pain and crisis in offering and sponsoring health health-care benefits. Without fundamentally fixing the driving force of current health-care escalating costs, and in case of next major failure from consumer-directed health plans and employee cost-sharing strategies, this nation will face and suffer from not only health-care crisis, but also labor crisis and national deficit crisis ($44 trillion deficit) from tax incentive sponsored, employee health benefits driven and health-care out-of-control infected disasters.

Wal-Mart bare-bones benefits strategy and Band-Aid fix and solutions to the U.S. healthcare and labor crisis will temporarily stop "local bleeding" (health care costs per employee 40% less than the U.S. average, Wysocki/Zimmerman, Wall Street Journal, 9/30) for no more than two years and will inevitably result in unintended backslash accelerating employer-sponsored health care benefits system collapsing and labor disasters.

Because Wal-Mart bare-bones benefits package discourages and precludes noncatastrophic medical claims but covers and "promotes" the catastrophic medical claims with no lifetime cap, that will practically quadruple the catastrophic medical claims in two years, with an upfront benefits saving by 40% and catastrophic benefits cost increase by 400% in the end.

Employer's Next Surprises and Crisis

Enron Case Moves Forward: Plan Fiduciaries Should Take Note (PDF) (Gardner Carton & Douglas)

Court Refuses to Dismiss Fiduciary Breach Claims in Enron Litigation (EBIA WEEKLY)

9/4/2003: Text of DOL Amicus Brief Supporting Money Damages Against Employer as Fiduciary in Life Ins. Case (U.S. Department of Labor, Office of the Solicitor)

Callery v. The United States Life Insurance Company in New York, No. 03-4097 (filed with 10th Cir. on Aug. 20, 2003).

 

Excerpt: "Star Buffet offered life insurance coverage to its employees through a policy issued by United States Life Insurance Company ... Callery was never provided with a summary plan description that outlined the life insurance policy's scope of coverage and exclusions, nor had the insurance policy itself been distributed to Callery or other Star Buffet employees."

9/4/2003: Text of DOL Amicus Brief on Claim Against Directors for Failing to Oversee Investment Committee (U.S. Department of Labor, Office of the Solicitor)

Excerpt: "The Complaint in this case alleges that the members of the Williams Company Board of Directors, who admittedly were charged with the duty to appoint, retain and remove members of the Benefits Committee, breached their fiduciary duties under ERISA by failing to monitor the Committee members and failing to provide them with the information that they needed to carry out their investment responsibilities."

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

November 8, 2002. Excerpt: "[W]e heard from an extraordinary array of able and thoughtful individuals, some representing professional organizations and some speaking on their own behalf.... There were ... important differences in perspectives, but there was also a surprising amount of agreement on where education can help fiduciaries perform better. We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

Employer Health Plan Nightmares ... and Other Things That Go Bump in the Night (Chang Ruthenberg & Long PC)

Medical Cost Reference Guide (BlueCross BlueShield Association)

Excerpt: "A key step to maintaining access to affordable healthcare is understanding the drivers of healthcare costs. To foster this understanding, BCBSA recently published the Medical Cost Reference Guide, a compendium of the best secondary research available focusing on the key drivers of healthcare costs."

HSAs Might Alter Group Health Coverage (Washington Post)

Excerpt: "A provision of the Medicare bill Congress passed this week would allow workers to turn a health insurance feature they normally dislike -- a high deductible -- into tax-free savings that could grow to large sums over a lifetime.... The provision could have a profound effect on employer-base medical insurance plans, some experts said."

Health Reform Losers, Winners (The Baltimore Sun)

Excerpt: "The $400 billion drug benefit Congress voted to add to Medicare is a brand-new entitlement for 40 million elderly and disabled people. But while some will do better with the new coverage, others will not. And some will likely do worse."

Union official urges health care reform-(Manitowoc Herald Times Reporter)

Op-Ed Contributor: The State of Health Care, in One Easy Number

Hewitt Study Shows Employers Critically Concerned with Health Care Costs and Looking for Creative Solutions

Hewitt Federal Legislation Quick Guide: June 15, 2004 (Hewitt)

Workers' health-care costs may continue rise (The Courier-Journal)

Health care costs shifting to employees, study finds (Rocky Mountain News)

Tracking Health Care Costs: Trends Slow in First Half of 2003 (Center for Studying Health System Change)

Health care costs continue double digit increase / Employees bearing more of the costs (Victoria Colliver, Chronicle Staff Writer )

Health Care Costs to Continue Climbing at Double-Digit Rates, According to Results of Latest Mellon Survey

Unknown Prices Hamper Health Care Reform Efforts (AP via Washington Post)

Excerpt: "Almost nobody, from the doctor to the patient, knows what a given procedure really costs. And that's a real problem for would-be reformers who favor a system that counts on consumers to hold down health care costs, by putting them in charge of their own spending."

'We thought we had insurance' (Sunday Gazette-Mail)

"Through most of 2002, they scrambled for help from their union and an array of state and federal agencies and elected officials. Nobody stopped the unfolding financial disaster. They were caught in a regulatory no-man’s land."

A High-Stakes Union Fight: Who Will Fold First? (Workforce.com)

The 2003 MetLife Study of Employee Benefits Trends (PDF) (MetLife)

Whose Problem Is Health Care? (New York Times)

"American companies have ingeniously managed to contain labor costs through productivity gains, outsourcing and limiting wages. But the factors over which manufacturers have less control - structural costs like those for corporate income taxes, employee benefits and rule compliance - have surged, according to a study released in December by two trade groups, the Manufacturers Alliance and the National Association of Manufacturers."

 

"After corporate income taxes, employee benefits are the second-largest structural cost for American manufacturers, adding 5.8 percent to costs, according to the study. In all major economies, paying for health care means a combination of public and private money. But in the United States, businesses pay a larger chunk than do their European and Asian counterparts."

 

"Uwe Reinhardt, an economist at Princeton, has referred to General Motors, Ford and Daimler-Chrysler as "a social insurance system that sells cars to finance itself.''

 

"Few business leaders advocate that government provide comprehensive health insurance for American workers not in Medicare - at least not yet. The National Association of Manufacturers would like the system to evolve from one in which employers provide benefits to one in which consumers buy health care."

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Health and Welfare Issues (PDF) (Towers Perrin)

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Retirement Issues (PDF) (Towers Perrin)

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Human Resources Issues (PDF) (Towers Perrin)

Opinion: Administration Proposal Could Weaken Employer-Based Health Insurance (PDF) (Center on Budget and Policy Priorities)

Soaring Health Care Costs Leave Little Companies in a Bind (New York Times)

USATODAY.com - Hospitals sock uninsured with much bigger bills

Binion's Targeted for Insurance Probe (casinocitytimes.com)

"LAS VEGAS -- Binion's Horseshoe and its owner, Becky Binion Behnen, are being investigated by the U.S. Department of Labor for possible violations of federal law involving $2.5 million in unpaid worker health insurance claims, officials said Friday."

"Pipal said there is little recourse for disgruntled physicians and their patients, because managed-care companies function under the Employee Retirement Income Security Act (ERISA) of 1974, a federal law with new provisions governing health care benefits."

California Grocery Workers Vote To Approve Contract, Ending Strike Over Changes To Health Benefits (KaiserNetwork.org)

Forbes.com: GM health-care costs rise despite Medicare change

GM's Future Retiree Health Obligations Total $60B, Even After Medicare Subsidies (KaiserNetwork.org)

GM says health care obligation hit $67.5 billion in 2003 (AP Wire | 03/11/2004)

"GM has said its total cash expense for health care is expected to climb to $5.1 billion this year from $4.8 billion in 2003. The bulk of the expense is for retiree benefits and prescription drugs.

Dubrowski said the expense saddles GM, Ford Motor Co. and DaimlerChrysler AG's Chrysler Group with liabilities many foreign rivals do not encounter.

 

"Before a car even leaves our factory it's got a $1,400 cost disadvantage relative to an overseas model," he said."

Judge ends health care coverage for 9,000 Weirton Steel retirees (Chicago Sun Times)

Fact Sheet: Affordable Health Care for America's Families (White House)

Bush makes fresh pitch for health care remedies, tax cuts (AP through San Francisco Chronicle)

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com)

Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

.......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

Opinion: HSA Rules from IRS Are Good Guidance (The Galen Institute)

Health Savings Accounts Ready To Enter the Market (Managed Care Magazine)

Health Insurers See New Role Managing Information

Hewitt Study Shows Majority of Employers Likely to Offer New Health Savings Accounts

Employers' Contradictory Views About Consumer-Driven Health Care (Health Affairs)

DOJ Sues Promoters of Schemes to Report Lower Taxes Using Sham Health Care Reimbursements (Employee Benefits Institute of America Inc. (EBIA))

Evolving Role of Third Party Administrators Brings New Demands and Innovations (Employee Benefit News)

Excerpt: "Gone are the days of third party administrators (TPAs) simply processing claims and cutting checks for Taft-Hartley plans. Today's TPAs are assisting their clients in everything from creating new benefit plan models to contain costs and boost worker recruitment and retention to providing the latest and greatest regulatory compliance counsel."

Staying Out of Jail Under ERISA's Bulked-Up Criminal Law Penalites (Attorneys Russell D. Shurtz and Craig R. Pett)

Excerpt:

"These are hefty increases. Few have focused on the fact that these bolstered penalties apply not only to black-out notices, but also to ERISA's other plain-vanilla reporting and disclosure requirements. The term "criminal penalties" seems so out of place with mundane things like SPDs, SARs, and other run-of-the-mill benefit plan documents."

What Sites Do You Visit To Keep Up with Employee Benefits Compliance and Design Developments? (BenefitsLink Wiki)

Bureau of Justice Statistics Medical Malpractice Trials and Verdicts in Large Counties, 2001  (Acrobat file) (Press release)

Incidence Benefits Measures in the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

New Statistics for Health Insurance from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

Trends In Employer-Provided Prescription-Drug Coverage (U.S. Department of Labor, Bureau of Labor Statistics)

Medical and Retirement Plan Coverage: Exploring the Decline in Recent Years (U.S. Department of Labor, Bureau of Labor Statistics)

New Benefits Data from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

The 2003 National Compensation Survey: a Wealth of Benefits Data (U.S. Department of Labor, Bureau of Labor Statistics)

Excerpt: "Worker health costs will rise a staggering 24% this year. Companies can no longer afford to pick up the bill. The battle is here."

Healthcare Costs Are Key Issue in Big 3 Automakers' Union Negotations (USA Today)

State Health Plans Cover More Workers Than Private Plans But Suffer the Same Cost Problems (Spencer Benefits Reports)

Health Care Costs To Continue To Climb At Double-Digit Rates In 2004 (Spencer Benefits Reports)

Health Care Costs Still Climbing at Double-Digit Rates, According to Results of Buck Consultants Survey (Mellon Financial Corporation)

2003 Employer Health Benefits Survey (The Henry J. Kaiser Family Foundation)

Employees Paying Ever-Bigger Share for Health Care (New York Times; one-time registration required)

California Bill for Employer-Paid Health Coverage to be Expensive, and Might Be Preempted by ERISA (San Francisco Chronicle via International Foundation of Employee Benefit Plans)

Overview: Pay or Play in California? (PDF) (Seyfarth Shaw LLP)

Opinion: Detroit's Healthcare Crisis-- and Ours (Geoffrey Colvin on Fortune.com)

UAW Made Concessions on Wage Increases To Preserve Health Benefits (KaiserNetwork.org)

GAO: Common Standards and Improved Coordination Needed for Insurance Regulation (U.S. General Accounting Office)

53 pages. Excerpt: "Market conduct regulation--oversight of insurance company practices such as selling and underwriting policies--is the responsibility of the same state agencies that oversee insurance companies' financial solvency. Unlike financial regulation, however, with its nationwide standards that allow for coordination among state regulators, no generally accepted standards exist for market conduct regulation.' Summary at http://www.gao.gov/highlights/d03433high.pdf

 

GAO Report: Health Insurance-- Federal and State Laws Affecting Coverage by Small Businesses (U.S. General Accounting Office)

63 pages. Excerpt: "GAO was asked to summarize current federal and state requirements for health coverage offered by small businesses, including mandated benefits, premium-setting requirements, and requirements regarding availability of coverage.' Summary at http://www.gao.gov/highlights/d031133high.pdf

Excerpt: "In an extraordinary gathering, the CEOs of some of America's largest companies - from Kellogg's to SBC Communications - called on Congress and the White House to stop dillydallying with band-aids for the nation's healthcare system and to come up with comprehensive, systematic reform."
 

CEO: Let’s Fix Health Care (Portsmouth Herald, NH - May 2, 2003)

Excerpt: "If there is to be reform of health care, it must be done by the business community, said Fisher Scientific International Chairman and Chief Executive Officer Paul Montrone Thursday at the University of New Hampshire’s CEO Forum.

Ford: Rising Health Care Costs a Problem (AP)

Excerpt: "Ford told the Detroit Regional Chamber's annual Leadership Policy Conference that the rising prices of health benefits is the "biggest issue on our plate that we can't solve."

 

"Health care is just out of control," he said. "It's a system that's broken. It really scares me enormously."

Employers Looking for More Help with Cost Reduction from Health Insurers, Third-Party Administrators (PLANSPONSOR.com; one-time registration required)

Excerpt: "Roughly three-quarters (73%) of employers say their health plans are not meeting expectations in terms of reducing insurance costs, and nearly two-thirds (64%) of employer respondents to a new survey say that current efforts being made by health plans are ineffective in reducing costs, according to a report from competitive intelligence firm Provizio."

Healthcare Cost Spiral Seen Continuing (Health - Reuters via Yahoo)

Excerpt:  "Despite concern about long-term cost trends, there seems to be little consensus about how to control overall healthcare spending while preserving access to high-quality care.

 

"There's really not very much cost-control going on at all other than employers moving to cost-sharing," Cassil noted."

Survey: Americans More Worried About Healthcare Costs Than Terrorist Attacks (The Henry J. Kaiser Family Foundation)

Excerpt: "We were surprised to find in our latest tracking poll that more Americans are worried about health care costs than about losing their job, paying their rent or mortgage, losing money in the stock market, or being a victim of a terrorist attack.

 

Nearly four in 10 Americans (38%) say they are very worried that the amount they pay for health care services or health insurance will increase, and a similar share (37%) is very worried that their income might not keep up with rising prices over the next six months."

Thousands of Former Bethlehem Steel Employees Scramble for Health Coverage (The [Philadelphia] Inquirer)

Excerpt: "More than 200,000 retired steelworkers and their dependents-- including 95,000 from Bethlehem Steel and its Lukens division-- have lost health-insurance coverage in recent years, as 37 steelmakers have gone into Chapter 11. Union leaders say it is just a matter of time before retirees in other industries-- such as airlines-- are faced with the same experience."

United Auto Workers Chief Says National Healthcare Program Required (Detroit Free Press)

Excerpt: "The head of the United Auto Workers put automakers on notice Monday: You can't stem rising health-care costs by shifting the burden to workers and retirees. The auto industry alone can't solve "America's health care crisis."

"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

Opinion: An Overview of the Troubling Medicare Legislation (Center for Budget and Policy Priorities)

Shifting Burden Helps Employers Lower Rate of Health Cost Increase (Dow Jones Business News via Yahoo! News)

Health Care Tops Taxes As Small Business Cost Drain (USA Today)

Excerpt: "For the first time in nearly 20 years, small businesses say soaring worker health costs, not taxes, are their biggest headache. Taxes had been No. 1 since 1986."

Excerpt: "Employees disagree with their employers about employees' responsibility to help restrain rising health care costs, according to a survey recently released by Towers Perrin. The national survey, Keeping Employees Engaged About Health Care, was conducted in February 2003 with individuals working for an employer with at least 1,000 employees and with employer-sponsored health care benefits.

An Employer's Guide to Patient-Directed Healthcare (65-page PDF book) (Wye River Group on Healthcare)

Overview: IRS Issues Guidance for New Health Reimbursement Arrangements (Watson Wyatt)

Analysis: Debit/Credit Card Medical FSA and HRA Reimbursements (PDF) (Milliman USA)

Federal Government Trying to Get Flexible On Employees' Spending (Washington Post via International Foundation of Employee Benefit Plans)
 

Consumers Take Charge: Defined-Contribution Health Plans (PDF) (The Wharton School of the University of Pennsylvania)

8 pages. Excerpt: "The goal is to temper rising costs and improve service quality by giving consumers better information and greater control over how they spend their health-care dollars. Defined-contribution plans won't replace managed care plans, but they will be the next dominant form."

Consumerism in Health Care: the Quest to Create New Partnerships for Responsibility and Accountability (PDF) (The Segal Company)

Aon Health Care Survey 2003 (pdf)

Harris Survey on Health Benefit Trends in California (California Health Care Foundation)

IRS Modifies HSA Eligibility Rule for 2004, 2005 for Individuals Covered by Prescription Drug Plan (PDF) (Internal Revenue Service)

Rev. Rul. 2004-38 Clarifies HSA Eligibility Rule for Individuals Covered by Prescription Drug Plans (PDF) (Internal Revenue Service)

IRS Provides Safe Harbor for Preventive Care Benefits Under High-Deductible Health Plan (PDF) (Internal Revenue Service)

HSAs Established Before April 15, 2005 Can Cover Expenses Incurred On or After January 1, 2004 (PDF) (Internal Revenue Service)

Frequently Asked Questions About Health Savings Accounts (HSAs) (U.S. Treasury Department)

Draft Form Issued by IRS: Model Health Savings Account for Use by Trustees (PDF) (Internal Revenue Service)

Draft Form Issued by IRS: Model Health Savings Account for Use by Custodians (PDF) (Internal Revenue Service)

With Doctors Envisions Altered Managed Care (New York Times)

Excerpt: "It also plans changes in a number of practices, like claims processing, that the doctors and the insurance company said would be worth about $300 million in savings for the doctors and the company. But Aetna said the changes would add only modestly to its costs because they were part of planned improvements in efficiency already under way."

 

"Dr. Rowe said the agreement should lead to lower costs for both the company and doctors. It will reduce doctors' overhead costs, he said, and Aetna will no longer be spending roughly $40 million a year on the legal costs related to the nationwide suit."

ERISA Demystified

1.     ERISA regulates up to 80% of health-care claims or 60% of health expenditures in the U. S. ($1.55 trillion in 2002), and has never been understood by health-care executives;

2.     American employers, plan sponsors and health-care executives have never been practically and meaningfully advised on ERISA education and strategy that covers ERISA statutes, regulations, case laws, claim procedure and dispute as well as health-care bottom-line: reimbursement under current managed care/ERISA environment;

3.     Health-care claim denial problems have fundamentally threatened health-care providers business survival;

4.     Up to 1/3 health-care claims was completely denied, rest of them partially and significantly denied.  Up to $600 billion claims were denied health-care claims in 2000.  Physicians Are at Breaking Point in heir Business Survival As a Result of the Managed Care Nightmare and Claims Denials under ERISA Shield

5.     $1.55 trillion were spent in national health-care in 2002, 14.9% of GDP, out of which $207.2 billion were out-of-pocket payments, rest of them are health-care claims through third party reimbursement claims

6.     Health insurance premium increased 14%-20% this year and almost every major health insurers are cutting jobs to cope with crisis;

7.     New trend in health-care funding and insurance from MSA, FSA, DCP as tax incentives to employee high premium and high deductible might fundamentally change U.S. health-care platforms;

8.     State law legislations (Prompt Pay and Patient Rights) have proven to be little or no protection (80% of ERISA claims); Patient Bill Of Rights, a revision of ERISA, will not provide any meaningful protection to health-care providers unless health-care executives really understand ERISA and its practical implementation in managed care environment, something remains to be mystery in reality and miracle in legislation;

9.     ERISA has been around for 28 years without any Executive 101 Briefing while ERISA relentlessly regulates 80 percent of U.S. health-care costs;

10.  New Federal Claim Procedure, to be effective January 2002, has been a monopoly for insurance/benefits executives but practically immune or allergic to health-care executives while it has provided health-care providers with best and maximal protections against improper denials of medical necessity, usual customary and reasonable, policy exclusion, PPO discount and pre-existing conditions, Q-C16, Q-C17, Q-D9 & Q-D10;

11.  Traditional Assignment of Benefits Form used in hospitals and physician's offices does not provide any rights for physicians to dispute with insurance companies over claim denials except for only receiving undisputed and paid claims, according to new government guidance for new claims procedure, Q-B2;

12.  Only with proper understanding of what constitutes a sufficient designation of authorized representative, as required by new regulation, to ensure you to obtain ERISA rights guaranteed by federal law and to enjoy maximal protection to protect your business survival and prosperity.

13.  Traditional Coding and Billing, documentation and electronic claim submission implementations have been proven marginal successful while many hospital’s reimbursement rate are well below 50%-25% across the country.

How Private Health Insurance Works: a Primer
 (Henry J. Kaiser Family Foundation)
Report 

NAIC Members Adopt Discretionary Clause Model Act

Excerpt: "Model Helps Ensure Consumer Health Insurance Claims are Subject to a Fair Review

PHILADELPHIA (June 9, 2002) — Members of the National Association of Insurance Commissioners (NAIC) today adopted the Discretionary Clause Model Act at the association’s Summer National Meeting here.

The act, which was developed by the NAIC’s ERISA Working Group, prohibits the use of discretionary clauses in health insurance contracts.

“Discretionary clauses are an effort to give an insurance company full and final discretion in interpreting benefits and administering an insurance contract,” said Maryland Insurance Commissioner Steve Larsen, who chairs the Health Insurance and Managed Care Committee. “This places consumers at a significant disadvantage when they are seeking to overturn the denial of benefits under an insurance policy.”...."

Consumer Protections under ERISA and California Law Compared
 (California HealthCare Foundation)

Excerpt: "ERISA prevents states from directly regulating health insurance arrangements established by employers, but allows states to regulate the indemnity insurers and health plans with which employers contract.... [C]onsumer protections vary depending upon whether an employer decides to retain the risk of paying medical claims (that is, to 'self-insure' the employee plan) or to purchase group insurance from a state-licensed insurer or managed care organization."