Self Employed Health Insurance

Washington -- The Children's Health Insurance Program reauthorization that President Obama signed Feb. 4 is just the first step toward universal health coverage, asserted Obama and Senate Democratic leaders.

"The way I see it, providing coverage to 11 million children through CHIP is a down payment on my commitment to cover every single American," the president said during the signing ceremony. The enactment of the measure was hailed by patient and physician organizations, including the American Medical Association.

Sens. Max Baucus (D, Mont.), chair of the Senate Finance Committee, and Edward Kennedy (D, Mass.), chair of the Senate Health, Education, Labor and Pensions Committee, sent a letter to Obama the next day stating their commitment to adopting universal coverage legislation this year. "We have a moral duty to ensure that every American can get quality health care. ... Incremental efforts will no longer suffice, and we cannot afford to wait any longer."

The CHIP reauthorization expands the program by $32.8 billion over 4½ years and is expected to cover about 4 million more children than the 7 million enrolled in the existing program. The new law will take effect April 1. As part of the federal government's new enhanced role in children's coverage, the law removes "state" from the program's name.

Obama on Feb. 5 also rescinded restrictions on CHIP eligibility that were issued by the Centers for Medicare & Medicaid Services on Aug. 17, 2007, and went into effect a year later. The so-called "Aug. 17 directive" barred a state from using federal matching CHIP funds to cover children in families at or above 250% of the federal poverty level unless the state had covered 95% of kids in families at or below 200% of poverty. CMS never officially enforced the policy, which was the target of lawsuits from several states seeking to protect their CHIP eligibility.

Sen. Jay Rockefeller (D, W.Va.), chair of a Senate Finance subcommittee on health care, said he's been fighting the directive ever since CMS unveiled it. "Our pleas finally have been heard by a president who shares our passion for children's health care," Rockefeller said.

The CHIP reauthorization allows states to receive enhanced federal matching funds to cover children in families earning up to 300% of poverty.

Senate in the lead

The Senate is at the forefront of current health system reform efforts, said Joseph Antos, PhD, a health care scholar at the American Enterprise Institute.

Kennedy and Baucus both have been holding committee hearings on health reform, but House Democrats have been less active on the issue. Baucus already has offered a 110-page outline of comprehensive legislation. This move, combined with the Feb. 3 withdrawal of former Sen. Tom Daschle from consideration for Health and Human Services secretary, has placed Baucus in the spotlight, Antos said. "Baucus clearly must feel that he's the go-to guy in the Senate."

CHIP will be expanded by $32.8 billion over four and one-half years.

The Daschle exit likely has delayed the Obama administration's health reform plans, said Nina Owcharenko, former legislative director for then-Rep. Jim DeMint (R, S.C.) and a health policy analyst at the Heritage Foundation. "A lot of the wheels probably are not up and running as quickly as they would like," she said.

Antos described the departure of Daschle as HHS secretary-designate as a bump in the road, but he added, "Is it a big bump? Who knows?"

Daschle's withdrawal probably hasn't changed the Democrats' health agenda, said Chris Jennings, a former senior health policy adviser to President Clinton. The Obama plan seeks to extend health coverage to the uninsured while allowing those with existing coverage to keep it. The president remains committed to health reform, Jennings said. But for a plan to be adopted, it will have to be seen as an American plan, not just one person's bill, he said.

Republicans seem to be taking a more reactive role in health reform, Antos said. "It's a party that seems not to be as focused as they might be at the beginning of a new presidential term," he said. Still, the Republican leaders of both chambers -- Rep. John Boehner (R, Ohio) and Sen. Mitch McConnell (R, Ky.) -- both have announced health reform policy working groups.

"House Republicans will not be content to be 'the party of no.' Instead, we will be the party of better solutions, and few issues demand more positive solutions than our nation's health care crisis," Boehner said Feb. 4. Rep. Roy Blunt (R, Mo.) is leading a panel of 15 House members who will craft Republican proposals. Four of the members are physicians.

McConnell's group, announced Jan. 12, consists of Sens. Mike Enzi (R, Wyo.), Charles Grassley (R, Iowa) and Orrin Hatch (R, Utah). Their task is to ensure that any health legislation in the Senate has GOP input, according to a McConnell spokesperson. Grassley and Hatch worked closely with Democrats to craft 2007 CHIP legislation that President Bush vetoed twice.

Hard work remains

The CHIP reauthorization is a significant advance in health coverage, said Ted Epperly, MD, president of the American Academy of Family Physicians. "I definitely see this as a sign that this administration is deeply committed to reforming and transforming health care in this country."

But the enactment doesn't make national health reform any easier to achieve, Owcharenko said. The Democrats benefited from having kids as the face of the legislation. "When we talk about overhauling the entire health care system, there are a lot of different faces, and a lot of them may be winners and a lot of them may be losers."

Dr. Epperly agreed that achieving wider health reform will remain a challenge, including replacing Medicare's physician fee formula with a sustainable pay system.

But because Medicare and other public programs are facing huge deficits, lawmakers in Congress are going to feel pressure to do something on the health system soon, Jennings said. "I've always been a believer that in health care, fear beats hope. This is a case where fear may drive all of the stakeholders to move very, very actively to promote health reform."

The print version of this content appeared in the Feb 23, 2009 issue of American Medical News.

Washington -- A federal appeals court said physician privacy dictates that a consumer group is not entitled to receive and publicize Medicare physician claims data. The court added that the information would not be of use to patients anyway.

Consumers' Checkbook/Center for the Study of Services sued, in 2006, the Dept. of Health and Human Services under the Freedom of Information Act to obtain selected physician claims data. The organization hoped to provide patients information on the number of major procedures performed in 2004 by each Medicare physician in four states -- Illinois, Maryland, Virginia and Washington -- and the District of Columbia.

The appeals court's Jan. 30 decision reverses a district court ruling of August 2007. It prevents both the data release and the publication of a free public resource that Checkbook/CSS had planned to produce using the information. The American Medical Association was successfully added to the case as an additional appellant after it urged HHS to challenge the lower court's ruling. While the appeal was pending, the release of the claims data was put on hold.

The AMA called the latest ruling a "major victory" for preserving physician privacy and for protecting patients who otherwise could have received bad data.

"We are in favor of patients having information that's evidence-based and statistically balanced, but the problem with the request by Consumers' Checkbook is that it's raw billing data, which could be misleading to society," said Jeremy A. Lazarus, MD, a psychiatrist from Denver and speaker of the AMA House of Delegates. "Unless it's tied to quality measures and an adequate patient size, then it could be damaging."

Checkbook/CSS anticipated that a patient could use the information when seeking a physician for a specific procedure. A patient could find out how many of these procedures a given doctor performed over the course of a year and choose a more experienced physician.

But that is not the only factor to consider when finding a physician, said Cynthia A. Markus, MD, an emergency physician and president of the Washington State Medical Assn. "Sheer volume of cases does not necessarily ensure quality. It may in fact indicate just the opposite."

The information requested by Checkbook/CSS "does not serve as a ratings system," said K. Edward Shanbacker, the Medical Society of the District of Columbia's executive vice president.

"It would have been misleading to patients if they had tried to extrapolate data from the Medicare program on a per-procedure basis. It doesn't speak anything about the physician's competence or quality," he said.

The U.S. Court of Appeals for the D.C. Circuit agreed in a 2-1 decision. The court weighed the "nonexistent public interest against every physician's substantial privacy interest" and concluded that exposure of the data "would constitute a clearly unwarranted invasion of personal privacy."

For instance, the data elements Checkbook/CSS sought included the diagnosis, type of procedure, place of service and the Medicare ID number of the physician who performed the service. Because related physician personal information is all publicly available online, as are the Medicare fees a doctor receives for performing a specific procedure, an individual could use the Checkbook/CSS resource to calculate the total yearly Medicare payments made to a specific physician, the court said.

Seeking greater transparency

Checkbook/CSS, a nonprofit that rates firms and services for subscribers, said the decision denies the public a powerful tool that could be used to assess the quality performance of doctors and the quality performance of the Medicare program.

"In the world of free speech, more information is better than less," said Robert Krughoff, president of Checkbook/CSS. "The court is way off track by saying people might misuse the information. Sure, it's a possibility, but it's not something that should be stopped."

Krughoff said his organization is considering its options and may request the court to re-hear the case "en banc," meaning all the members of the appellate court would weigh in. While its initial request under the Freedom of Information Act only included the four states and the District of Columbia, he said interest in obtaining claims data likely would spread to other states.

Because Medicare officials have launched initiatives to ensure quality health care through accountability and public disclosure, Krughoff questioned why the government chose to fight this disclosure. "Governments are not always enthusiastic about transparency when it means their own performance will be judged."

But the court did not buy that connection. "We fail to see how the requested data will allow the public to evaluate the performance of any specific quality-promoting programs [Medicare] has a statutory duty to undertake," the ruling stated.

An HHS spokesperson said the department has no comment on the court's Jan. 30 ruling because the pending suit has not yet been dismissed. But the department has stated a commitment to making Medicare claims data available as allowable by the law. In challenging the suit, it cited a 1979 ruling by the U.S. District Court for the Middle District of Florida that prohibited it from disclosing Medicare pay data that would have identified individual doctors.

Krughoff lamented the AMA's impact on the case.

"I wish the AMA had come out on the other side of this," he said. "They have been strongly against it. But I don't think that means all individual physicians oppose it. I don't know if the government would have appealed without the AMA's involvement."

The print version of this content appeared in the Feb 23, 2009 issue of American Medical News.

A federal appeals court decision addresses the scope of federal anti-kickback and self-referral laws while raising several caution flags over joint financial agreements between physicians and hospitals.

A panel of the 3rd U.S. Circuit Court of Appeals found that a hospital failed to meet the personal services exception under federal referral regulations, known as Stark, when it contracted with an anesthesiology group. The exception generally allows physicians to contract with a hospital entity to provide particular services -- as long as the agreement meets certain criteria and does not violate federal laws prohibiting illegal referrals between entities that share a financial stake.

Carlisle Hospital and Health Services in Pennsylvania contracted exclusively with Blue Mountain Anesthesia Associates PC in 1992 to provide anesthesiology services at the facility in exchange for free office space, equipment, supplies and staff. In 1998 the hospital, now Carlisle Regional Medical Center, built an ambulatory surgery center and pain clinic. The anesthesiologist began providing pain management services there, also while receiving space, equipment and other support at no charge.

Carlisle argued the arrangement was an extension of the original 1992 contract, which referenced pain management even though the services were not widely provided at the time.

But the 3rd Circuit disagreed in a Jan. 21 opinion, saying the new deal opened up possibilities for illegal referrals and failed to meet a host of safe harbor requirements.

Unlike hospital-based practices such as anesthesiology, which do not involve referrals, "in pain management, a physician in an outpatient facility is in a position to generate substantial business for a hospital," the court said. In addition, "the only written contract in existence ... was negotiated in 1992 in a context wholly different from the one that existed six years later after the opening of the pain clinic."

Judges found the 1992 agreement did not detail the pain management relationship at the separate facility or any related compensation arrangement -- such as free space and equipment -- as required by the personal services exception. Because no renegotiation of the compensation terms occurred, there was no way to determine if they reflected fair market value, another requirement under Stark, the court said.

Carlisle is considering asking the full 3rd Circuit to rehear the case.

Strict standards

The ruling is one of only a few that interpret exceptions under federal Stark standards -- typically addressed through advisory opinions -- and lends further guidance on the complicated regulations, said Jeffery P. Drummond, a health care regulatory expert and partner with Jackson Walker LLP in Dallas.

"The message is: It doesn't matter how reasonable and defensible the underlying arrangement is if you don't meet all of the [Stark] requirements. And it has to be in writing," he said. "Even if [an agreement] is documented, whenever there is a big change, make sure it's updated."

The decision also highlights an additional liability risk for physicians, as well as for the hospitals with which they contract, warned Philip H. Lebowitz, a Philadelphia lawyer specializing in health care fraud and abuse.

The case was initiated by a whistle-blower under the False Claims Act, he noted. Because the court determined a Stark violation existed, it allowed the plaintiff to pursue his claim that the hospital had improperly billed the federal government for pain management services provided under the illegal arrangement.

"That connection is probably something that's here to stay," said Lebowitz, a partner with Duane Morris LLP. Although the physician group was not named as a defendant in this whistle-blower case, doctors might be liable in such arrangements under Stark or false claims violations, he added.

Physicians often rely on hospitals to handle contract details. "But after this decision, they really need to be careful themselves that there's an agreement in place that accommodates whatever financial relationships they have with hospitals or other entities they refer to," he said.

Carlisle's attorney Larry B. Selkowitz disagreed that Stark and anti-kickback laws were implicated, because no referrals were involved. "These were hospital patients in a provider-based clinic completely integrated in all respects with the main hospital."

Because the off-site pain clinic was connected to the hospital -- by offering patients who needed further care full access to all of Carlisle's services -- the hospital qualified under Medicare regulations to submit claims on behalf of the clinic, said Selkowitz, a former assistant U.S. attorney.

Once Carlisle opened the pain clinic, however, outside referrals did come into play, said G. Mark Simpson. He represented the whistle-blower in the case, Ted D. Kosenske, MD, who left Blue Mountain Anesthesia Associates in 2005 to open an independent pain management practice.

If Carlisle could continue to bill for non-hospital patient services, "Medicare ends up paying well more than if the same service had been provided across the street in a doctor's office, even though there is no additional benefit to the patient," Simpson said. The decision "addresses the exact situation Stark was intended to address ... and clearly establishes if you want to rely on a Stark exception, you better make sure the relationship is transparent."

The print version of this content appeared in the Feb 23, 2009 issue of American Medical News.

As a human being, and as an individual in your own right, who interacts with several people on a daily basis for whatever reason, I am sure you have considered self analysis as a way of discovering yourself, and traits in yourself that you have noticed and admired, or denounced in others around you.

If you indulge in this sort of exercise, then it can only be extremely good for you, because it proves that you are assessing your self worth through self analysis.

Have you ever stopped to wonder what self worth and self esteem signify, and what the terms ego, mental and emotional strength, and self concept mean to you?

Take the example of Jim. He belonged to a poor family which could rarely afford three square meals a day, everyday, and whose father was an alcoholic.

He had always imagined being rich and owning fine things, and being able to eat out in fine restaurants.

This was the image he had built up in his mind of a successful person, and when he grew up and found that he was not as popular as he thought he would be, and that failure met him at every turn, he became embroiled in a vicious circle of self hate and inadequacy, leading him to keep company with ‘losers’.

This is a perfect example of what a loss of self esteem and self worth after self analysis may do to a person.

In Jim’s case, the poor man became a clone of his father, who never treated his family well, and he found that he could not get out of this cycle.

Remember; you have to be comfortable with your own self worth, because this is tied in with your ambition and your ability to achieve your heart’s desires.

• Make sure that your thoughts are for the most part positive and optimistic and constructive, and consciously throw out all negative thoughts and feelings from your repertoire everyday.
• Remember that the unconscious mind is very impressionable, and it builds up a set of images and feelings based on your experiences. Therefore, it would be a great idea for you to use rational and conscious thoughts to generate visuals based on the realization of your dreams. This will attract your desires and help you attain a level of comfort with positive feelings, so that you will be able to take the necessary steps for improvement by yourself.
• Everyday, make it a point to dream of what you really want, and learn to eliminate thoughts that make you unhappy or uncomfortable. The more happy and comfortable you become with your new desires and dreams, the easier it will be for you to achieve them.

Persist, and success will soon come knocking at your door!

Love is not only essential for happiness, but has also been shown to reap health benefits.

Be it romantic love, marriage, or a vigorous sex life, love has been shown to ease all sorts of ills.

Recent research has shown that male mice with female companions live longer and are also able to reproduce at a much older age.

Despite having no real direct physical effect, merely having love and companionship can keep you healthy and fit.

Marriage and Lifespan

The fact that married men live longer than single men is well known. Men who are married are twice as likely to see a doctor and are more likely to see that doctor sooner.

Married couples generally have more of an income flow. While money isn’t the only thing that’ll make you happy, those with better incomes are able to afford better healthcare and healthier food.

Also, those who are married are less likely to use alcohol, less likely to commit suicide, less likely to have accidents, and less likely to suffer from medical problems such as heart disease, stroke and cancer.

Generally, married couples have stronger immune systems than those who are single. Mental disorders like schizophrenia and depression are also lower in marriages.

Benefits of Love in General

Love in all contexts has been shown through research to have health benefits. Those who report feeling loved by someone experience:

• Fewer heart problems
• Lower cholesterol
• Less overall pain
• Fewer headaches
• A stronger immune system

This love can come from marriage, dating or a strong friendship.

Hugging Benefits

Women who hug have healthier hearts and lower blood pressure. Research from the University of North Carolina found that women have lower levels of cortisol if they hug.

Long-term snuggling has the same effect as blood pressure medication. No wonder hugging feels so good.

Sex Benefits

Sex has been found to have numerous health benefits. Those who have regular sex will have:

• Lower blood pressure
• Lowered stress
• Higher immunity
• Burned calories
• Better cardiovascular health
• Pain reduction
• Lowered prostate cancer risk
• Stronger pelvic muscles
• Better sleep
• Better sense of smell
• Less depression
• Better bladder control
• Better teeth

Bad Relationships

While love is fantastic for health, bad relationships can be very harmful. Hostility and dominant behavior has been shown to harden the arteries around the heart. Divorces, difficult parents and unstable friends can create stress.

Stress can cause all sorts of health problems like backaches, insomnia, increased cancer risk, menstrual problems, fertility problems, heart disease, sexual problems, headaches, gastrointestinal disorders, lower immune system and skin problems.

Dealing with Relationship Stress

The best way to deal with relationship stress is to remain calm. If the relationship is not essential, you might want to end the relationship.

But if you are unable to end the relationship, you must manage your emotions. If you are feeling depressed, focus on energizing yourself by speeding up your activities.

If you are feeling angry, get some caffeine and try to slow down your activities to a crawl if possible. Your goal should be to maintain a stable balance of emotions. Also, try to limit your time with the unhealthy relationship if possible.

Another way to handle relationship stress is to remember that everyone is human and that your relationship partner might not realize what he or she is doing. Try talking things through.