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at 11:57:03 AM on Friday, November 21, 2003

New Federal Health Claims & Appeals Laws & Regulations for 193 Million Americans Effective 09-23-2010 ©2010, Jin Zhou, ERISAclaim.com
President Obama Signing Health Bill on 03/23/2010		President Gerald R. Ford Signing ERISA on 09/02/1974
New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans
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Patient Protection and Affordable Care Act Statutory Laws [PDF] [PDF]   Affordable Care Act Regulations and Guidance Interim Final Rules on Internal Claims and Appeals and External Review Processes: News Release • Regulation • Fact Sheet • NAIC Uniform External Review Model Act Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections: Regulation • Fact Sheet • Patient Protection Model Notice • Lifetime Limits Model Notice • Dependents Model Notice Grandfathered Health Plans: Fact Sheet • Regulation • FAQs • Table • Model Notice Extension of Coverage For Adult Children: Fact Sheet • Regulation • FAQs • IRS Guidance FAQs on Health Care Reform and COBRA   House Committees Health Insurance Reform at a Glance: Summary • Implementation Timeline • Consumer Protections • For Employers White House Web Page on Health Reform HHS Health Reform Web Site
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U.S. Healthcare Crisis Turnaround:
A New Diagnosis and $1.0 Trillion Nuclear Solution To
$44 Trillion Future U.S. Budget Deficit

By Jin Zhou

© Jin Zhou,  ERISAclaim.com

03/01/2003 Published
11/14/2005 Updated
 

Happy or Sad 30th Birthday To ERISA? (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) Sept. 2, 2004 On Sept. 2, 1974, exactly 30 years ago today, ERISA, The Employee Retirement Income Security Act, was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and welfare plans, to provide uniform federal protections in response to the failure of the Studebaker Co. in December 1963, with thousands of long-service employees cheated out off their promised pensions, and to preempt any state laws when the employees pension and welfare benefits were threatened. 30 years later, ERISA Failure in its compliance and enforcement left thousands of retirees without medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout. ERISA Failure Syndrome U.S. Healthcare Crisis Trilogy   Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare "Failure of Imagination" Again?     Statement by President Gerald R. Ford Upon Signing the Employee Retirement Income Security Act of 1974

ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension Insurance Program (Spencer Benefits Reports) Excerpt: "The seed for ERISA was planted with the failure of the Studebaker Company in December 1963, leaving thousands of long-service employees without their promised pensions."

ERISA Failure Syndrome U.S. Healthcare Crisis Trilogy (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)
ERISA Medical Killing		ERISA Medical Inflation		ERISA Insurance Robbery
	?   ?		?   ?		GAO-04-312 ?   ?
American Job ExportING!		Mass layoffs up in January 2004		Weirton Steel cancels 10,000 GM: $67.5 billion in 2003
US pension agency chief warns of solvency risk (Reuters) The Looming National Benefit Crisis (USATODAY.com) One Nation under Debt: U..S. economy threatened by aging of America NATIONAL DEBT COLLISION COURSE MEDICARE CALCULATOR METHODOLOGY ►HIDDEN COSTS ►DEMOGRAPHICS ►RISING COSTS ►YOUR SHARE ►EXPLAINOR   Healthcare Disaster at Fault Verdict Index: U.S. Government 30% U.S. Employers & Insurers 30% Healthcare Providers 30% Consumers 10% (ERISA Failure + Managed-Care) Destroyed US Healthcare (ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks   GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005 Rising Health care Costs Have Many Implications (Direct) Rising Healthcare Costs Have Many Implications (Indirect)   Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2   Health costs a big part of GDP (Newsday.com) February 9, 2005   "Socolar and Sager co-direct Boston University's Health Reform Program, which attempts to develop solutions to the nation's health care problems. In the report released today, they argue that if health care costs had grown no faster than GDP, the nation would have saved a stunning $1 trillion."   Excessive Medical Expenses Study Finds that Half of Health Care Dollars Are Wasted (San Francisco Chronicle)   Excerpt: "About 50 percent of health care spending is eaten up by waste, excessive prices and fraud, according to a report set for release [February 9, 2005] by Boston University researchers. Major sources of unnecessary spending include administrative costs and profit in the insurance industry, high prices of prescription drugs and health services and, to a smaller extent, theft and fraud, according to the study."

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

ü      Establish Prudent "Personal Responsibility" without Eliminating Employer-Sponsored Health-Care System and without "Skipping Necessary Health Care" and "Personal Bankruptcy";

ü      Keep Employer-Sponsored Health-Care System with Quality Health Care but without Skyrocketing Cost Disaster

The year 2004 is almost over for a healthcare crisis driven nation when we all have been fantasizing practical solutions from political Hollywood and self-destructive Disneyland. Now it's time to do some reality check:

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."

The Cost of Health Ins. Administration in Calif.: Estimates for Insurers, Physicians, & Hospitals (Health Affairs)

11 pages: "ABSTRACT: Administrative costs account for 25 percent of health care spending, but little is known about the portion attributable to billing and insurance-related (BIR) functions. We estimated BIR for hospital and physician care in California. Data for physician practices came from a mail survey and interviews; for hospitals, from regulatory reporting; and for private insurers, from a consulting company. Private insurers spend 9.9 percent of revenue on administration and 8 percent on BIR. Physician offices spend 27 percent and 14 percent, and hospitals, 21 percent and 7–11 percent, respectively. Overall, BIR represents 20–22 percent of privately insured spending in California acute care settings."

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."

Summary: Employer Costs for Employee Compensation -- December 2004 (U.S. Bureau of Labor Statistics)

Excerpt: "Employer costs for employee compensation averaged $25.57 per hour worked in December 2004, the U.S. Department of Labor's Bureau of Labor Statistics reported today. Wages and salaries, which averaged $18.07, accounted for 70.7 percent of these costs, while benefits, which averaged $7.50, accounted for the remaining 29.3 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". 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.

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 ...."

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."

Calif. attorney general launches insurance probe

"SAN FRANCISCO, Oct 29 (Reuters) - California's Attorney General Bill Lockyer has launched an investigation into possible antitrust violations and fraud by insurance companies and brokers, his office said on Friday."

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.

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

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

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

"Employers large and small say they're feeling the pain of higher medical costs. Yet many seem willing to go along -- if they can -- no matter how influential they may be.

 

General Motors (GM), the nation's third-biggest company in terms of sales, saw health-care costs rise 37 percent, to $4.8 billion from $3.5 billion, for 1.1 million workers, retirees and their family members in the last four years."

Treasury Secretary Says Health Costs Impede Growth (Reuters via Medscape)

Excerpt: ""The rising cost of health insurance is bad for the small business community, and it impedes growth in the overall American economy," Snow is due to say to a meeting of leaders of small businesses, according to a draft copy of his planned remarks obtained by Reuters."

GM chair, Pfizer head disagree on cause for skyrocketing health costs

"A failure to address escalating health care costs could result in the loss of entire industries in the United States, Wagoner said"

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

Cost Of Health Care A Threat, Snow Says - from TBO.com

Health care costs threaten GM (Lansing State Journal)

""If there was one thing that stood a chance of bringing down General Motors, Ford and perhaps DaimlerChrysler, it would be health care costs," said auto analyst Jim Gillette of CSM Worldwide."

Federal government runs $344B deficit - billingsgazette.com

"WASHINGTON (AP) - The government ran a deficit of $344.3 billion in the first eight months of the 2004 budget year, according to the latest snapshot of the nation's balance sheets."

 
"So far this year, the biggest spending categories are programs from the Health and Human Services Department, including Medicare and Medicaid, $356.7 billion; Social Security, nearly $349 billion; military, $285.2 billion; and interest on the public debt, $190.5 billion."

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."

GAO Chief Urges Major Health Care Overhaul (Reuters via Yahoo! News)

GAO: Comprehensive, Fundamental Reforms to Control National Healthcare Spending (pdf) (U.S. General Accounting Office) (May 2004)

38 pages. Excerpt: "While health care spending appears affordable for another decade or two, added spending over time will draw resources away from other economic sectors and could induce adverse economic implications for government, individuals, and other private purchasers of health care.' Executive summary at http://www.gao.gov/highlights/d04793sphigh.pdf

US pension agency chief warns of solvency risk (Reuters)

"WASHINGTON, Oct 7 (Reuters) - The longer-term solvency of the U.S. agency that insures pensions is at risk, threatened by troubled airlines and other companies failing to fund their retirement plans, the agency's director said on Thursday."

Greenspan Issues Warning on Retirement Benefits (The New York Times)

"JACKSON HOLE, Wy., Aug. 27 — The chairman of the Federal Reserve, Alan Greenspan, warned today that the Federal government might have to scale back promises to the elderly in programs like Social Security and Medicare."

Study from the Commonwealth Fund Biennial Health Insurance Survey Ties Workers' Health to Benefits (PDF) (The Commonwealth Fund)

16 pages. Excerpt: "Low wages and a lack of job-based health insurance are a deleterious economic combination for working American families. With the average annual family premium in even the group market reaching $10,000 in 2004, purchasing private coverage on their own is often not an option for families who already face stark compromises due to the costs of housing, food and clothing, and transportation.¹⁵ And many people, depending on age, gender or health status, would likely face even higher premiums in the individual market or not qualify at all because of pre-existing conditions.¹⁶ Most workers and their families who are not offered coverage through jobs are thus left with the consequences of being uninsured in the United States: poor access to the health care system, lack of preventive health care services, and the enormous stress of knowing that the lack of coverage could result in crushing financial debt."

U.S. Comptroller Warns On Benefit Costs (National Underwriter Hot News, Jan. 14, 2005)

“If there's one thing that could bankrupt this nation, it's healthcare costs,” he said. “That's probably the only thing.”

Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

• Rising Health care Costs Have Many Implications
• Rising Healthcare Costs Have Many Implications

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."

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

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)

USA: GM chief talks health care as Republicans convene: Auto News "Wagoner reportedly said much of the discussion in Washington tends to centre around a complete, free-market system on one extreme, and a national health care programme [similar to the UK’s National Health Service] on the other.   "I suspect we're not going to end up with either one of those solutions," he told the Associated Press. "So if we could get people working on stuff in the middle ... I think there'd be some real improvements made."
Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare "Failure of Imagination" Again? Health care costs threaten GM (Lansing State Journal) ASO+HMO+PPO-SPD=$1.8 Trillion/Y US Healthcare Crisis   ERISA+SPD-HMO-PPO-ASO=50% Savings  GM chairman collides with health care, trade (Chicago Tribune)   The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings: ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions; ERISA Compliant Claims Procedure as the Only Rule for Every One; Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity" GM Current Model: $5.1 billion/yr, $1,400/vehicle) (GM says health care obligation hit $67.5 billion in 2003)  Black Hole (Forbes.com) "Rick Wagoner has been screaming about GM's health care expenses for a while. The situation is even worse than he says it is." Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2
Health Spending Projections Through 2013 New Federal Claim Regulation (Final Rule) Benefit Claims Procedure Regulation (FAQ) Amendments to Summary Plan Description Regulations (Final Rule) Patient's Rights Claims Procedure Regulation (Fact Sheet) U.S. Health-care Crisis & ERISA Criminal Enforcement CBO's analysis of the President's budgetary proposals for fiscal year 2005 Fact Sheet: Affordable Health Care for America's Families (White House)   Zhou's Medical Inflation Projection Through 2008: $1,000 Deductible (HDHP / HSA) + $1,500 Discount (HHS / Indigence) [Deductible + UCR + PPO Disc.]  =  "Discretionary Spending" + "Price Gouging" =   500% Medical Inflation in 5 years Docs Urged to Collect Fees -- Co-Payments and Deductible Payments -- Up Front (MSNBC News)
DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf) Compliance Assistance for Group Health Plans (Top 15 Tips)	950,000 MD's Settled With Aetna & Cigna on ERISA "Aetna and CIGNA Settlement Secrets" ERISA Certification Programs for Maximal Reimbursement	What You Should Know about Filing Your Health Benefits Claim HIPAA Nondiscrimination Requirements Frequently Asked Questions

December 03, 2004: NEW CMS STUDY SHOWS MEDICARE, MEDICAID PAID FOR MORE THAN HALF OF ALL SENIOR HEALTH CARE

Age Estimates in the National Health Accounts (pdf), Sean P. Keehan, Helen C. Lazenby, Mark A. Zezza, and Aaron C. Catlin

National Health Accounts: Age Estimates, Personal Health Care in selected years

Inquiry on Medicare Finds Improper Limits on Choices of Health Care Providers (The New York Times; one-time registration required)

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"

AS the number of Americans without health insurance for the entire year has reached at 43.6 millions, about 15.2 percent of the population and employers' health costs are expected to rise 12% next year, our entire nation continues to disregard  a clear diagnosis of our crisis and failure with unique health care system sponsored by employers under ERISA, the president and Congress have failed to take the prescription for resuscitation of a very critical condition of our healthcare system and labor-pension and benefits crisis!

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 impented 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%."

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.

Survey: Health Care Reform a Major Issue for Voters Fund Publications and Journal Articles (All Publications Are Free) The Affordability Crisis in U.S. Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey Archive of March 29 Webcast
Findings from the Health Insurance Survey and Policy Implications: Karen Davis, President, and Sara Collins, Senior Program Officer, The Commonwealth Fund PowerPoint Slides	Labor and Consumer Perspectives on the Findings: Gerald Shea, Assistant to the President for Governmental Affairs, AFL-CIO PowerPoint Slides	Business Perspectives on the Findings: Helen Darling, President of the National Business Group on Health PowerPoint Slides

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)

Unless US Supreme Court completely clarifies ERISA pre-emption, DOL practically and meaningfully enforces ERISA claim regulation for health care industry and ERISA fiduciary duties for pensions and retirement system, ERISA's fatality at its 31 year-of-age will bankrupt or disrupt this country,  completely contrary to congressional intention for enacting ERISA in 1974.

After a report was shelved by White House that showed the United States faces future federal budget deficits of more than 44.2 trillion dollars and the US government is at risk of being overwhelmed by the 'baby boom' generation's future healthcare and retirement costs, a most comprehensive study commissioned by then-Treasury secretary Paul O'Neill, our former treasurer boss, Mr. Paul O'Neill, realized immediately that healthcare care skyrocketing costs will be the main driving force to bankrupt the best country on the planet and to jeopardize American people's security. Three months before his resignation, he told our nation that "We can cut 50 percent of the cost of health care in this nation and improve service at the same time. 'This is not some wild theory'," as reported by The Hartford Courant on September 24, 2002.

After being confronted by the most comprehensive U.S. Government assessment of $44.2 trillion future budget deficit we are facing, and escalating healthcare crisis being the main killer, worst than terrorists, for American dreams, and the report Commissioner's assessment of 50% healthcare cost cut being the possibility and necessity for our national security, everyone should be deadly serious about $44.2 federal budget deficit crisis.

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."

"The problem is pretty urgent, and we don't have any time to start dealing with these problems," Gokhale told CNN/Money. "If we do nothing today, the cost of postponing action grows over time."

In addition, the final Medicare drug bill that  was signed into law on 12/08/2003 by  the President will cost an estimated $395 billion over ten years, some experts are at Opinion: An Overview of the Troubling Medicare Legislation (Center for Budget and Policy Priorities)

Experts at Center for Budget and Policy Priorities pointed out: "Of particular concern on the fiscal front is the legislation’s failure to include true cost-containment provisions that would moderate the escalating cost of drugs to both the federal Treasury and American consumers." 

CBO Issues Warning on Rising Health Care Costs - Reuters, December 19, 2003 "The Congressional Budget Office warned on Friday that an aging U.S. population and rising health care costs threaten to burden future generations with sky-high taxes and a mountain of debt if Medicare, Medicaid and Social Security benefits stay the same."

CBO Report: the Outlook for Social Security (PDF) (Congressional Budget Office)

Social Security: Distribution of Benefits and Taxes Relative to Earnings Level (U.S. General Accounting Office)

ABCNEWS.com : Analysts: Future Budget Outlook Gloomy

"Analysts Find Future Budget Outlook Gloomy Even With Higher Taxes, Spending Restraint"

Congressional Budget Office - CBO FTP for 'The Long-Term Budget Outlook'

The Executive Summary of This Congressional Budget Office report on December 19, 2003 concludes that skyrocketing health care costs is the main driver of budget deficit disaster and containment of health care costs as a key solution to future United States federal budget deficits crisis.

Executive Summary (Page xi):

Excerpt: "As health care costs continue to grow faster than the economy and the baby-boom generation nears eligibility for Social Security and Medicare, the United States faces inevitable decisions about the fundamentals of its tax and spending policies. This Congressional Budget Office report looks at a range of possible paths for federal spending and revenues over the next 50 years and combines them into various hypothetical scenarios. Analysis of those scenarios suggests the following conclusions:

Driven by rising health care costs and an aging population, spending on entitlement programs—especially Medicare, Medicaid, and Social Security —will claim a sharply increasing share of the nation’s economic output over the coming decades.

Fiscal policy could be financially sustainable if the growth of health care costs slowed significantly from historical rates. But even in those circumstances, tax revenues would probably need to be higher than they have been in the past."

Bureau of Labor Statistics, released on JANUARY 29, 2004, has shown that more than half, 51%, of the increases in compensation costs was attributable to benefits costs increases, mainly health insurance benefits.

"Among private  industry workers, the pattern of compensation gains was similar, with  benefit costs attributing 51 percent of compensation gains during the  September to December period.  Health insurance and defined benefit  retirement contributions accounted for approximately three-fifths of the gain in benefit costs." (Employment Cost Index news release text)

"U.S. Treasury Secretary John Snow today (04/22/2004) told the annual meeting of the Bond Markets Association in New York that the federal budget deficit is "too large" and "has to be dealt with.........Yet Snow remarked that the system itself, whereby employers cover health care costs for most individuals, is in need of a transformation to "make us act like good consumers." (Ari Weinberg, 04.22.04, Forbes.com)

Forbes.com: Snow Prescribes Reform For Health Care (Ari Weinberg, 04.22.04, 3:49 PM ET)

"There must be a fundamental fix in the way we deliver health care," said Snow. From 1998 to 2002, according to Snow, health care costs rose 35%. In 2003 alone, he said, insurance premiums for business rose 14%. Federal spending on medicare and medicaid accounted for 3.9% of gross domestic product in 2003. Increasing at a rate of growth of GDP plus 1%, those costs will rise to 11.5% of GDP by 2050. The Bush administration would like to see federal spending on medicare and medicaid rise at the same rate as GDP, bringing it to only 6.4% of GDP by 2050.

Snow said "it should be doable but will require the very best efforts of all of us."

But even Mr. Paul O'Neill did not say specifically how we're going to cut 50% of escalating healthcare costs with $1.55 trillion health-care expenditure in 2002, and the latest national survey indicated that "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.

So the question is how we're going to cut healthcare costs by 50%, while "US companies are mad as hell at HMO premiums".

Are All Consultants Corrupt? (Fast Company)

A New Diagnosis:

The following listings are the most objective and comprehensive assessment of health-care failure and employee benefits failure from every significant and controlling aspects of US regulatory, judiciary, insurance and benefits industries, and legislative landscapes:

ERISA preemption of state laws, "discretionary authority" practice for both self-insured and fully-insured plans, deferential judicial review standards, "Administrative Service Only" (ASO) practice for self-insured plans and "discretionary clause" practice for fully-insured plans, managed-care HMO and PPO contracting practice to substitute and disregard ERISA claim regulation and Summary Plan Description (SPD) with mass patient enrollments in such managed-care plans, The president/DOL hands-free "enforcement" of ERISA ("ERISA industry self-enforcing"), American employer's hands-free "leadership" and employee benefits administrations without any ERISA compliance at all coupled by suicidal legislative initiatives ("ERISA industry self-enforcing"), health-care providers, American workers and patients complete lack of knowledge of ERISA, insurance and benefits industry short-term profit driven strategies entertained by special interest groups with severe conflict of interest, especially in providers community, by misleading and/or practically useless, crisis promotion and contradicting but most costly legislation and runaway litigations, and Congress "crisis management" principle with complete clueless of ERISA failure as health-care managed-care failure to crisis and coming disasters.

 

The current U. S. managed-care model is a detrimental and fatal healthcare model, which is not ERISA compliant, nonfiduciary ASO (Administrative Service Only) hijacked through provider contracting, by capitation (HMO) and network discounts (PPO), to violate and disregard SPD (Summary Plan Description), and utilization reviews with cost-containment labels to destroy safety, quality and efficiency of healthcare system, and artificially manufacturing administrative hurdles in healthcare delivery system by violating and disregard ERISA Claims Regulation. After two decades of managed-care practicing, more PPO discounts have resulted in more skyrocketing double-digit overall cost increasing through medical inflation, more HMO enrollments and cost-containment have resulted in Patient Bill of Rights Legislative campaign, medical malpractice lawsuit explosions and malpractice premiums crisis with tort reform legislative initiatives. The benefits and saving generated from first a few year of managed-care practice has been completely exhausted with current backslash of more than a decade of distrust, hostile and ERISA noncompliant fatal consequences in our healthcare delivery system, and more detrimentally, this ERISA failure syndrome has caused entire employee benefit crisis, pension crisis and labor market crisis with union strike explosion and American job export triggered economical and political crisis.

 

(Specific discussion of this comprehensive discovery is beyond editorial scope of this publication, additional inquiry for interpretations and solutions are available through individual consultations)

Inquiry on Medicare Finds Improper Limits on Choices of Health Care Providers (The New York Times; one-time registration required)

ERISA Failure Syndrome U.S. Healthcare Crisis Trilogy (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)
ERISA Medical Killing		ERISA Medical Inflation		ERISA Insurance Robbery
	?   ?		?   ?		GAO-04-312 ?   ?
American Job ExportING!		Mass layoffs up in January 2004		Weirton Steel cancels 10,000 GM: $67.5 billion in 2003
The Looming National Benefit Crisis (USATODAY.com) One Nation under Debt: U..S. economy threatened by aging of America NATIONAL DEBT COLLISION COURSE MEDICARE CALCULATOR METHODOLOGY ►HIDDEN COSTS ►DEMOGRAPHICS ►RISING COSTS ►YOUR SHARE ►EXPLAINOR   Healthcare Disaster at Fault Verdict Index: U.S. Government 30% U.S. Employers & Insurers 30% Healthcare Providers 30% Consumers 10% (ERISA Failure + Managed-Care) Destroyed US Healthcare (ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks   GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005 Rising Health care Costs Have Many Implications (Direct) Rising Healthcare Costs Have Many Implications (Indirect)   Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2   Health costs a big part of GDP (Newsday.com) February 9, 2005   "Socolar and Sager co-direct Boston University's Health Reform Program, which attempts to develop solutions to the nation's health care problems. In the report released today, they argue that if health care costs had grown no faster than GDP, the nation would have saved a stunning $1 trillion."

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

 

"Class Actions" v. "New Strike Force"   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)   "Helped by lower-than-expected health care cost increases, managed care companies’ net income increased by 40.3% for the first nine months of 2004, according to a report by Oldwick, N.J.-based A.M. Best Co. The 15 largest managed care companies reported total profits of $6.17 billion for the nine months ending Sept. 30, 2004, compared with $4.40 billion in the year-earlier period. "

Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org   "In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact." Health care now prime target of federal False Claims Act (AM News) "No place for fraud" "There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

 

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

 

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

 

 

DOL + DOJ Enforcement of ERISA

 

&

    

 

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

 

State Insurance Department in All 50 States

Promote & Coordinate with ERISA  NAIC ERISA Working Group

Health Benefits Laws By State (Interactive Tools From Insure.com) Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF) (Council for Affordable Health Insurance) Kaiser statehealthfacts.org Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University)
	View a 5-minute clip Paper Chase
ERISAclaim.com - U.S. Health-care Crisis & ERISA Criminal Enforcement
		To Avoid "John Q. ERISA Enforcement"

Like it or not, no one disagrees that our health-care system is in the worst crisis with health care costs hitting the breaking point, with family values, American security and dreams being ruined, with possible  future U.S. budget deficit ($44 trillion deficit).

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%."

No one is likely to agree that current U.S. health-care crisis is completely and solely created and caused by everyone of us, and no one has intention to fix our current health-care crisis if anyone of us has to criticize and change ourselves in fulfilling our own obligations and responsibilities to avoid and resolve our health-care crisis, including health-care providers and their associations, insurance companies and TPA's, American employers and employees, our Congress and federal as well as state governments. No solutions will work unless we have correct and true diagnosis.

Most of the time we're all competing in creating more and more health-care crisis so that we would never have time in fixing "more and more health-care crisis".

As of today, all of the efforts in "fixing" health care cost and crisis are mainly focused on shifting the costs to employers with higher premiums by insurers, shifting costs to employees with higher deductibles and co-pays by employers or shifting costs to federal government with tax incentives by politicians or HMO/PPO UR for punishing the patients by reducing important care, and some seemingly expert work on segmental and incidental repair on antifraud and disease management as well as contracting reengineering.

How does this national solution work so far?

There are more job losses with uninsured and medical inflation!

Job Losses in U.S. Cut Hospital Earnings as Unpaid Bills Mount (Bloomberg.com)

"April 26 (Bloomberg) -- Emergency rooms from Atlanta's Grady Memorial Hospital to the Detroit Medical Center are being overwhelmed by a surge in visits from patients who can't pay and lack insurance because they lost their jobs.

Uninsured emergency room visits rose 26 percent in March at HCA Inc., the biggest U.S. hospital chain. California-based Tenet Healthcare Corp., the second-largest, and Triad Hospitals Inc. in Texas report the same trend as the number of unemployed has risen to 8.4 million and the uninsured to 44 million.

``We are close to a meltdown,'' said Dr. Arthur Kellermann, 49, who runs the ER at Grady Memorial and also heads Emory University's department of emergency medicine. ``You're going to see a major hospital system go under.''

HCA Previews First Quarter Results:

"Uninsured emergency room visits rose 18 percent in the first quarter and 26 percent in the month of March, while uninsured admissions rose 14 percent in the first quarter and 19 percent in March compared to the same periods of 2003. In addition to the significant increase in first quarter 2004 bad debts, the Company's health care facilities provided $218 million of charity care and discounts to the uninsured, up from $182 million in the first quarter of 2003."

None of the present mainstream solutions are fundamental reform to fix  the true and real culprit and etiology of U.S. health care failure and crisis.

While everyone is pointing finger at others and proclaiming his/her own version of magic cure, no one disagrees that while country is facing a possible war with Iraq and sluggish economy, the Congress is far from providing any timely solutions to our urgent crisis, not to mention if  Congress ever had a real solution in the first place.

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."

With the GE strike with the death of Kjeston "Michelle" Rodgers and an estimated jump in the number of strikes by as much as 20% over the next few years and a staggering 24% increase in worker health care costs this year, with reported 75 million Americans being uninsured at some point of 2001-2002, the entire country is struggling and suffering from pain and fearing for the worst.

It is uncertain if everyone will agree that if our national "Damaged Care" under current healthcare crisis continues to worsen, American John Q.. out from Hollywood (play the Preview from "View the trailer") might come to our every hometown of USA, a new worst terrifying war that no one can stop, even with U.S. Supreme Court order for "PEGRAM et al. v. HERDRICH II"

As many of us believe that If with known intelligence of sufficient and precise hints and leads, and if our government acted with prudence, September 11 disaster could have been avoided, but our government insists there is no sufficient and precise hint or lead prior to the September 11 disaster. At the price of worst tragedy in our nation's history, retrospectively we may all agree that had we paid enough attention to those reports of Congress library, Minneapolis memorandum and Phoenix memorandum, the results and reality might be different.

Our congress concludes the "Failure of Imagination" by our leaders and institution is to blame for 9/11 tragedy.

Our healthcare failure is also caused by our leader's Lack of Imagination" Again for "John Q. ERISA Enforcement".

History repeats itself, we're making the same mistakes in health-care crisis as we may have made in fighting terror war.

We ignore the basic facts, avoid our own responsibilities, enjoyed monopolies for our own noncompliance, we take shortcuts, pointing fingers at others only, we seek for quick fix and magic cure without fixing real crisis and fundamental failure, we turn to the Congress for solutions to avoid our own responsibilities by reinventing, recycling and salvaging legislations to create more crisis of our own by reckless disregard of any practical solutions in existing laws and regulations, self-inflicted crisis through quick fixing and profit gain ("uninsured coverage" and "punitive damage therapy"), and blaming others for our own mistakes.

For our urgent and worst health-care crisis, the Congress will not have timely solutions and does not have magic cure or the right answer, because the answers and solutions are in our own hands but we refused, and because no one in Congress truly understand what exactly went wrong with our health-care system and none of us have interest and the time to look at real diagnosis and prescriptions for our health-care crisis, as we did for those reports of Congress library, Minneapolis memorandum and Phoenix memorandum prior to September 11 disaster. A similar and parallel mistakes may have happened with our February 1 space shuttle Columbia disaster.

NASA's flu of "people just relegated to crossing their fingers and hoping for the best?" is exactly what our nation is doing for the compliance of existing ERISA of 28 years of age and new ERISA claim regulation in the history of final years of health-care crisis to health-care disaster, and possible national economy recession.

Those diagnoses for our national health-care crisis presented to Congress are symptoms diagnosis without understanding of real cause of the problems.

Those legislative prescriptions and solutions presented to the Congress are symptoms fix only, without fixing the fundamental problems of health-care crisis, without any real therapeutic results but with subsequent severe complications that will worsen any existing problems.

No one would like to handle the truth, the truth hurts.

Overall, American employers, health insurers and third party claim administrators would like to make our health-care system to work as much as any other Americans, you're not as bad evil and conspiratory as perceived by the some general public, as you have tried very hard to make it work without knowing what exactly is the fine line for being a good cop and a bad cop, the governing laws and regulations in health insurance claims processing and adjudication: ERISA, Employee Retirement Income Security Act of 1974.

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

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

Contrary to the popular belief,  our nation's health-care crisis has been truly and mainly caused by the lack of understanding and failing in compliance with ERISA, the federal law regulating about 80% of health-care claims or 60% of health expenditures in the U. S.  for 28 years by both insurance/benefits industry and health-care providers, American business leaders hands-free leadership on employee benefits management as well as health-care industry and managed-care culture, through reckless and fraudulent as well as revengeful, inflationary spiral billings and claim denials that destroyed or foreclosed the  hope, faith and the Law & Order for our nation in health-care quality and cost control, and the lack of meaningful and practical federal administrative enforcement of ERISA claim regulations, because this inflationary spiral skyrocketing increases in managed care claim and denial war behind ERISA shield between health insurers/ERISA plans and healthcare providers have overwhelmingly outnumbered increases in cost of living and national gross domestic products, causing annual double-digit increases in health insurance premiums and skyrocket health-care costs ($1.55 trillion in 2002, 14.9% of the U.S GDP) after every managed care strategy and model failed to contain or control health-care costs in long run despite short-term savings, while entire country has devoted more and more money in litigation, legislation and noncompliant managed care campaign, which practically have solved little or no problem.

ERISA failure, failure in ERISA compliance and ERISA enforcement, with state law preemptions in past 30 years has  exposed "consumers to unlimited and frequent premium increases, and the potential for rampant fraud with little, if any, regulatory recourse."

AHPs Are The Wrong Answer For Small Businesses (BCBSA News, 02/03/2005)

"BCBSA and more than 1,300 small business, healthcare provider, consumer and state government organizations oppose federal AHPs. This broad-based coalition believes that AHPs would expose consumers to unlimited and frequent premium increases, and the potential for rampant fraud with little, if any, regulatory recourse."

MarketWatch: Illness And Injury As Contributors To Bankruptcy -- Himmelstein et al., 10.1377/hlthaff.w5.63 -- Health Affairs

 

"ABSTRACT: In 2001, 1.458 million American families filed for bankruptcy. To investigate medical contributors to bankruptcy, we surveyed 1,771 personal bankruptcy filers in five federal courts and subsequently completed in-depth interviews with 931 of them. About half cited medical causes, which indicates that 1.9–2.2 million Americans (filers plus dependents) experienced medical bankruptcy. Among those whose illnesses led to bankruptcy, out-of-pocket costs averaged $11,854 since the start of illness; 75.7 percent had insurance at the onset of illness. Medical debtors were 42 percent more likely than other debtors to experience lapses in coverage. Even middle-class insured families often fall prey to financial catastrophe when sick."

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"

While our nation has been relying upon magic with managed care with PPO discount and HMO capitation, "The Health Crisis Index rose from 22.5 percent in 1987 to 30.9 percent in 2003, rise of nearly two-fifths. It reached new heights in 2001, 2002, and 2003."

Health Crisis Index Rose 37 Percent, 1987 - 2003: Higher Spending Associated with Uninsured Number (PDF) (Boston University School of Public Health)

13 pages. Excerpt: "[The authors] have constructed a Health Care Cost and Coverage Crisis Index by adding health care's share of U.S. gross domestic product to the share of Americans lacking health insurance (also called the HCCCCI or the Health Crisis Index). The Health Crisis Index rose from 22.5 percent in 1987 to 30.9 percent in 2003, rise of nearly two-fifths. It reached new heights in 2001, 2002, and 2003."

We are so smart each time to win the cost battle against our own counterparts but to lose the entire war with $1.9 trillion national healthcare expenditure for 2005.

$100 Billion Lost Each Year in ``America's Hidden Healthcare Crisis,'' HSS Research Shows (www.tmcnet.com)

"The U.S. healthcare industry is losing upwards of $100 billion each year due to payment errors, which increases the cost of care paid by American businesses and consumers and further jeopardizes the solvency of the Medicare Trust Fund."

Some health care costs unnecessary (APP.COM)

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.

PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004)

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.

Trends in Usual and Customary Prices for Drugs Commonly Used by Medicare and Non-Medicare Enrollees (U.S. Government Accountability Office)

"Overall, we found that the average usual and customary prices for 77 prescription drugs frequently used by Medicare enrollees increased 21.8 percent from January 2000 through June 2004, a 4.6 percent average annual rate of increase. During the same period, the average usual and customary prices for 79 drugs frequently used by non-Medicare enrollees increased at a similar rate—22.8 percent, a 4.8 percent average annual rate of increase. (See enc. II for the annual percentage change in average usual and customary prices for drugs frequently used by Medicare enrollees, and enc. III for the monthly trend in these prices for drugs frequently used by Medicare enrollees and those frequently used by non-Medicare enrollees.) We also found that average usual and customary prices for 52 frequently used brand drugs increased about three times faster than for 47 frequently used generic drugs. Specifically, from January 2000 through June 2004, the average usual and customary prices for the brand drugs increased 26.4 percent, a 5.5 percent average annual rate of increase, whereas prices for generic drugs increased 8.3 percent, a 1.8 percent average annual rate of increase. (See enc. IV for the annual change in average usual and customary prices for brand and generic drugs.)"

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)

 Year 2004

• Medical Inflation Rates by Delivery System - Western U.S.
• Medical Inflation Rates by Delivery System - Nationally

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

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

Excessive Medical Expenses Study Finds that Half of Health Care Dollars Are Wasted (San Francisco Chronicle)

Excerpt: "About 50 percent of health care spending is eaten up by waste, excessive prices and fraud, according to a report set for release [February 9, 2005] by Boston University researchers. Major sources of unnecessary spending include administrative costs and profit in the insurance industry, high prices of prescription drugs and health services and, to a smaller extent, theft and fraud, according to the study."

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....

 

For the top 40 hospitals, the study found medical supply markups of up to 9,593%, drug charge markups as high as 6,796%, and operating room markups of up to 1,950%. In other words, the hospital that leads in supply charges puts an average sticker price of $9,593 on supplies that cost the hospital on average $100. On drugs, the national average sticker price was a 399% markup -- an increase of more than 50 points over prior IHSP findings......

 

The IHSP study cites the list price charged by hospitals. Typically Medicare as well as HMOs and other large third party payers negotiate discounts on final payment. But high charges also prompt higher payments by Medicare and the other payers, a fact increasingly recognized in the current national debate on charges."

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 "Discretionary Price Gouging".

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

Davis Testimony: Hospital Pricing Practices Need Reform [the House Ways and Means Committee's Subcommittee on Oversight.]   

Hospital Pricing Behavior and Patient Financial Risk

"Cracks in our fragmented health care financing system are jeopardizing the health and financial security of millions of Americans," Fund president Karen Davis said in invited testimony June 22 before the House Ways and Means Committee's Subcommittee on Oversight. "A major effort should be mounted to identify ways of reducing hospitals' administrative costs and simplifying payer rules and pricing practices," she urged. June 2004

Uninsured Reached 45 Million in 2003:  US Census Press Releases

"The number of people with health insurance increased by 1.0 million to 243.3 million between 2002 and 2003, and the number without such coverage rose by 1.4 million to 45.0 million."

 

Income, Poverty, and Health Insurance Coverage in the United States: 2003 (P60-226)

 

Health Insurance Data (Source: U.S. Census Bureau) (10 years on the web)

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

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

ERISA Failure Syndrome U.S. Healthcare Crisis Trilogy (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)
ERISA Medical Killing		ERISA Medical Inflation		ERISA Insurance Robbery
	?   ?		?   ?		GAO-04-312 ?   ?
American Job ExportING!		Mass layoffs up in January 2004		Weirton Steel cancels 10,000 GM: $67.5 billion in 2003
The Looming National Benefit Crisis (USATODAY.com) One Nation under Debt: U..S. economy threatened by aging of America NATIONAL DEBT COLLISION COURSE MEDICARE CALCULATOR METHODOLOGY ►HIDDEN COSTS ►DEMOGRAPHICS ►RISING COSTS ►YOUR SHARE ►EXPLAINOR   Healthcare Disaster at Fault Verdict Index: U.S. Government 30% U.S. Employers & Insurers 30% Healthcare Providers 30% Consumers 10% (ERISA Failure + Managed-Care) Destroyed US Healthcare (ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks   GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005 Rising Health care Costs Have Many Implications (Direct) Rising Healthcare Costs Have Many Implications (Indirect)   Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2   Health costs a big part of GDP (Newsday.com) February 9, 2005   "Socolar and Sager co-direct Boston University's Health Reform Program, which attempts to develop solutions to the nation's health care problems. In the report released today, they argue that if health care costs had grown no faster than GDP, the nation would have saved a stunning $1 trillion."

Managed Care concept and model were designed in the beginning to contain the escalating costs by contracting of capitation and participating provider discount and increasing utilization management to reduce unnecessary and defensive medicine practice, promoting preventative medicine to avoid disastrous medical costs, but still under the regulatory frame and environment of the ERISA with statutorily mandates of fiduciary obligations to make claim decisions in the best interest of plan participants and beneficiaries and to defray reasonable administrative expenses, because most Americans workers and their families obtained their health insurance primarily from employment in private sectors, and because insurance industry likes ERISA statutory infrastructure and frame of no punitive damage (ERISA Shield) (MASSACHUSETTS MUT. LIFE INS. CO. v. RUSSELL) and discretionary authority clause , advantageous to traditional insurance contract litigation of punitive damages as a remedy.

Fiduciary relationship and obligations are much higher standards and trust than "implied good faith and fair dealing" as required by conventional commercial insurance contract and relationship under state laws. Within fiduciary relationship, an ERISA plan fiduciary was given discretionary authority to make decisions in the best interests of plan participants and beneficiaries instead of its own best interest, while traditional insurance contract relationship allows the insurer to make decisions in its own best interest instead of the insured, so long as the decisions were made in accordance with policy terms and conditions and in good-faith and fair dealing. ERISA is intended by Congress to operate on the trust, commercial insurance is designed to trade premiums for assuming risks.

However without an understanding of such statutory mandate of trade off between "No Punitive Damage" and "Fiduciary Duties in the Best Interest of Plan Participants and Beneficiaries", insurance companies, ERISA plans and endless chain of middlemen of Managed Care Enterprises kept and enjoyed ERISA's no punitive damage and discretionary authority in making quick and big profits but simply ignored or refused ERISA fiduciary obligations of highest trust for doing everything in the best interest of plan participant and beneficiaries, American workers and their families, by recklessly depriving the access to necessary care and keep any decision-making confidential without any reasonable disclosures (Hernandez vs. Prudential), that has caused American workers, and their employers eventually changed their mind on the magic promised by managed care and that has caused health-care providers hopelessly struggling and relentlessly fighting back, some with inflammatory and revengeful spiraling billings for most health-care claims because of no disclosure from insurance company's and TPA's and nowhere to turn for help under managed care sky. This is also true even when physicians, as primary-care physicians contracted under capitated fee arrangement in HMO's were given the authority to make decisions on patient care, would also unreasonably deny their patients reasonable and necessary care for possible financial incentives under both doctor and patient fiduciary relationship and ERISA fiduciary and plan participant relationship.

Some health care costs unnecessary (APP.COM)

This national managed care nightmare has finally resulted U.S. Supreme Court ruling on June 12, 2000 in PEGRAM et al. v. HERDRICH: Because mixed treatment and eligibility decisions by HMO physicians are not fiduciary decisions under ERISA,....". And two years later Supreme Court ruled in RUSH PRUDENTIAL HMO, INC. v. MORAN, that ERISA does not preempt state law in external review for medical necessity, and subsequently a federal appellate court in New York ruled, on February 11, 2003 in CICIO v VYTRA HEALTHCARE,  that an HMO can be sued for medical malpractice if a medical treatment decisions was made in the course of ERISA claim administration.

Two decade history established that any monopoly for our own noncompliance will backfire on ourselves. Short-term symptomatology fix will cause disastrous crisis in our health-care systems.

Our entire nation ignored the etiology of managed care failure and health-care crisis, insurance companies and benefit industry proposed no discussion and reform for ERISA and focusing on uninsured Americans, health-care providers and patients advocates insisted on revising ERISA with punitive damages provisions, while current managed care failure has produced more and more uninsured Americans and no physicians and no health-care providers ever understood and utilized any state utilization review and external review laws even after U.S. Supreme Court ruling in RUSH PRUDENTIAL HMO, INC. v. MORAN. When insurance industry with HIAA and AAHP is focusing on uninsured Americans, and Representative Charlie Norwood resubmitted his revised Patient's Bill Of Rights without liability and punitive damage provisions, America employers are painstakingly wondering how to avoid another GE style strikes of 20 percent increase in the this year, and American families are getting nervous each day, in hope John Q.. won't have to come out from Hollywood to their hometown.

The worst thing is that in this long course of two decades of managed care practice, almost no one from health-care providers to employers, insurance companies, TPA's and American workers understand what ERISA is, what SPD is, what ERISA appeal is.

Strangely and ironically no one want to understand, complying with and enforce ERISA, the very protection designed by congress and clarified by U.S. Supreme Court.

Do we really want to know why our company employee benefits practice for health care has failed to work, simply opened one office for one day for our employees to complain about their health insurance problems;

Do we really want to know why our company customer service and appeal division have failed to work, simply listen to them for one hour as to how they are confused and why they have to do Internet research on ERISA on their own;

Do we really want to know why managed care has failed to work for health care providers, simply come to one of the Health Care Claim Denial and Appeal Seminars for providers, we might be "too shamed" to reveal our identity at the seminar;

Ask ourself a simple question as to how much we know about the ERISA and ERISA Claim Procedures.

We may find we do NOT know anything about ERISA, because we don't have time for 28 years and we really don't want to know about ERISA.

Some will complain that compliance with the ERISA will cost too much. Because the ERISA compliance is mandatory instead of optional, the question should be "how to maximally comply with ERISA at the minimum cost", otherwise we will never have highway transportation system, telephone system, Internet system as infrastructures in this country.

According to latest Milliman USA study, published on 02/20/2003, for Blue Cross Blue Shield Association, "we conclude that an increased focus in delivering customer service and an increased investment in information technology to meet the requirements of Y2K and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), has driven cost increases during the past five years."

More than 20 year history and health-care crisis have taught us one worse than terror lesson: The health-care through employment under the ERISA has absolutely failed without compliance of the ERISA, any creative managed care practice and innovation, if ERISA noncompliant, will repeat the current managed care failures, and eventually break and destroy our health-care system through short-term profit gain and long-term uncontrollable escalating health-care costs and health insurance premiums, irreconcilable litigations and ultimate labor force and marketplace disasters.

How do we know if this diagnosis is true in reality?

Plain and simple, imagine what would happen if the U.S. healthcare superhighway transported $1.55 trillion for 283 million Americans each year without an understanding, without compliance by any one and without the enforcement of any existing laws and regulations governing those 80% of the healthcare claims, 60% of the healthcare expenditures and 163 million Americans under ERISA?

A newly published Book has more legal and comprehensive analysis on this issue, Strangers in the Night: Law and Medicine in the Managed Care Era, by Peter D. Jacobson, J.D., M.P.H., Associate Professor,Department of Health Management & Policy, School of Public Health, University of Michigan,  reviewed (via healthaffairs.org) by M. Gregg Bloche, MD, JD, professor of law at Georgetown University, an adjunct professor at Johns Hopkins University's Bloomberg School of Public Health, and editor of The Privatization of Health Care Reform: Legal and Regulatory Perspectives (Oxford Univ. Press, 2003).

A new article provides clues on this issue too: The Failed Jurisprudence of Managed Care, and How to Fix It (pdf) Abstract by RUSSELL B. KOROBKIN, JD, University of California, Los Angeles - School of Law.

The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, 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, examined the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review, and discovered the urgency and necessity of expertise of ERISA claim procedure specialists. The study concludes the following in its summary and policy implications: "....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."

"......In this environment, contractual coverage and medical-necessity issues that persist are likely to be for services that enrollees feel especially strongly about. Such consumer concerns, together with ongoing consumer protection agendas that include reforms such as guaranteed external review and right-to-sue provisions, mean that the policy importance of UR denials in managed care is unlikely to wane in the foreseeable future."

However these best experts "hired" by Congress and federal government are one step away from the complete discovery and solution. Let us fill in the missing links and connect dots in order to save our health-care system from collapsing and crisis.

First, we identify the controlling force and power in contractual policy coverage denial. The majority of Americans are covered under the employer-sponsored health-care programs in private sectors under ERISA, 80% of the claims and 60% of health expenditures are regulated under ERISA. Each individual ERISA plan offers different coverage and benefits, either self-insured or fully-insured through purchase of insurance from an insurance company. The controlling and governing document for each ERISA plan is Summary Plan Description (SPD), the rule of the game for interpreting each SPD and resolving the disputes on contractual denials is ERISA claims procedure regulations. Therefore the experts from Harvard & Rand study group discovered the importance and necessity of "contractual expertise" but aborted the solution of "contractual expertise" due to "the reasons of size or financial stress, this may be beyond the reach of smaller medical groups that have assumed responsibility for UR".

Financial burden and unavailability of this contractual expertise could be the final resolution to their study group to determine if those contractual denials were made by the plan or TPA correctly.

Clinical knowledge and expertise from those medical groups are inherited, but "contractual expertise" is missing badly for policy coverage, Summary Plan Description (SPD) and ERISA Claims Procedure for 80% of health care claims, because such ERISA contractual expertise is nowhere to be found, even for those very experienced health care attorneys and insurance coverage experts, as state law governed insurance policy dispute resolution and ERISA governed claims procedure dispute resolution are quite different, and entire country has never put ERISA into health-care practice. This is why our health-care system failed.

Another new Rand/Harvard study published on February 2004 issue of Annals of Emergency Medicine, "Disputes over coverage of emergency department services: A study of two health maintenance organizations" discovered that 90% of denial in utilization reviews were overturned on appeals, from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs. This study concludes: "The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard."

This new Rand/Harvard study warns that "Although the end result for consumers is the same in each of these cases, the messages sent by plans to consumers and medical groups are not. Goodwill payments imply inappropriate use of the ED (notwithstanding the fact that actual merit might not have been assessed). Merit-based overturns, on the other hand, signal an error in utilization review and instruct medical groups about the proper limits of coverage, instructions that medical groups cannot ignore because they must meet the cost of these claims. Hence, merit-based overturns perform a valuable signaling function, akin to the role of judicial precedent in the law. Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable, goodwill payments of potentially meritorious cases limit opportunities to forge consensus about the limits of the prudent layperson standard and to disseminate accumulated knowledge about its meaning."

Importantly, ERISA claim regulation and definition of "claim involving urgent care", 29CFR2560.503-1 (m)(1) - Claims Procedure, has provided governing solutions to "disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard." for these privately insured enrollees. And "Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable," and ERISA claim regulation and  definition of "claim involving urgent care'', goodwill solution will result in backslash for more disasters in Emergency Department across the country.

If 80% of the health-care claim and 60% of health expenditures are governed and regulated by ERISA, ERISA plan's "insurance policy" is controlled by each plan's Summary Plan Description (SPD), and each claim dispute is resolved under ERISA claims procedure regulations, such "contractual expertise", called for by our Rand/Harvard experts, must be from ERISA claim procedure specialists.

Therefore, it is absolutely clear that our nation must provide a solution to health-care crisis by urgently establishing an industry or profession that will possess not only clinical expertise but also, and more importantly, ERISA contractual expertise, ERISA claim procedure expertise.
 

Now that both Aetna and CIGNA have settled the class-action lawsuits by 950,000 physicians and agreed to process appeals in accordance with ERISA claim regulations for both ERISA claims and non-ERISA claims, and to establish external review boards for Billing and Coding Disputes, Medical Necessity Disputes and Policy Coverage Disputes, in compliance with state external review laws, however external reviews will not be available until internal appeals/ERISA appeals are completely exhausted.

All other 8 major insurance companies named in class-action lawsuits have refused to settle, even if federal court would rule for physicians, the Aetna and CIGNA settlements will be "as good as it could get" from the rest of insurers and MCO's as evidenced in Aetna and CIGNA settlements with physicians.

"Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals 80% of the time.

The Latest AMA (PSA) Managed Care Hassles Survey through nationwide state medical associations and national medical specialty societies identified the most popular and important managed-care claim denials and delays.

Unless physicians understand and complete ERISA internal appeals, all of those "a love fest" and "victories" from class-action settlements would mean a fantasy of "a love fest"  to any physicians.

The answer is very simple for our prescription and solutions to our managed care failure and health-care crisis.

Do we have other choices other than ERISA Compliance?

Little or nothing is publicly known for 29 years by most health-care attorneys, employers, employee benefit professionals, health insurers, health-care claim TPA's, health-care providers and American workers, patients about ERISA, and ERISA claim procedure for  appeals.

A majority of preservice appeals disputed choice of providers or contractual coverage issues, a problem that is ultimately governed by SPD, Summary Plan Description under ERISA, or insurance policy for non-ERISA plans. If disputes involve ERISA plans, even for fully insured health group plans, ERISA is the choice of law, instead of state insurance laws and consumer protection laws. SPD design, distribution and education as well as benefits communication prior to the physicians visits may well or reasonably resolve or minimize choice of providers or contractual coverage disputes, this can be done by ERISA SPD compliance.

Medical necessity disputes were caused by societal uncertainty about legitimate boundary of insurance coverage due to lack  of SPD compliance, of availability of ERISA education and communication, societal uncertainty of ERISA preemption of state utilization review laws, ERISA claim procedure, lack of compliance in ERISA appeal process by both the claimants and ERISA plans, especially health-care providers, lack of compliance of any state utilization review laws and external review laws, lack of disclosure of identities of medical reviewers and relevant plan document and clinical guidelines used in making medical necessity determination. Everyone is taking shortcuts, no one bothered to file ERISA appeals. New federal/ERISA claim regulation is designed to solve this problem, yet little is publicly known about this new regulation, as original ERISA provisions in past 28 years, no sign of any public interest in educating, implementing, compliance and enforcement of this new federal/ERISA claim regulation, but entire country is overwhelmed with "uninsured coverage campaign" and" punitive damage therapy."

Greater transparency about the coverage status of specific services, through compliance of ERISA and SPD provisions, through more precise contractual language, as required by ERISA § 102 (a), to be calculated to be understood by average American workers and health-care providers, and to include  required contents by new SPD final rules.

Through consumer education about benefits limitations to include health insurers, benefits professionals,  TPA's, health-care providers and patients,  to communicate and to disclose any SPD provisions on benefits entitlement and limitations and exclusions as well as UCR Fee Schecdules. The entire country is debating and fighting for coverage limitation and exclusions while no one checks the issue against a copy of SPD, Summary Plan Description, of individual ERISA plan in managed care disputes, even some health-care attorneys fought coverage dispute cases all the way through to the court without ever referencing or requesting for a copy of SPD.

If controlling and governing law, ERISA is well understood and known by the public, including health-care providers, patients and insurance companies as well as TPA's, ERISA claim procedure is complied by every party involved, a large portion of disputes in managed care could be avoided, resulting significant amount of savings from $1.55 trillion U.S. Healthcare expenditure for the year 2001, that might well cover more uninsured Americans than any other proposals in Congress.