Jeffrey Segal, MD, JD - Medical Justice

Humana and the Exclusions — Why Healthcare Reform is of Vital Importance

August 15, 2024February 4, 2010 by Jeffrey Segal, MD, JD

Humana sent out a sales pitch from John Terry, Vice President, Sales. “You may be able to switch to a HumanaOne plan that could lower your monthly premiums.” Count the caveats in that? “May” and “Could” and “switch”… all presuming, of course, that you’re not only insured, but insurable. This pitch was aimed towards the self-employed amongst us, and calls those people “self-insured.” They even congratulate the self-insured on the ability to switch health insurance plans. (“Applications are subject to underwriting approval. Waiting periods, limitation, and exclusions may apply.”) Append extensive sales pitch and claims that you “may” be pleasantly surprised by their rates. (I may be the secret son of JFK too, but I’m not holding my breath on that either. — Ed.) Then, at the bottom, there is a list of conditions for which you “may be denied coverage, if you have been diagnosed with, or in the last five years* (varies by state) been treated for, any of the following conditions:

“AIDS/HIV, Anorexia or Bulimia, Cancer, Chronic Obstructive Pulmonary Disease (COPD), Crohn’s Disease, Depression, if hospitalization required, Diabetes, Emphysema, Fibromyalgia, Heart Attack Stroke or Angioplasty, Hepatitis or Liver Disease, Organ or Tissue Transplant…” It goes on to say that individuals who are severely obese, underweight or undergoing or awaiting the results of diagnostic tests, treatments, surgery, biopsies, or lab work may also be denied coverage. Ditto expectant mothers OR fathers, or children under 2 weeks of age.”

Breaking News

August 15, 2024February 4, 2010 by Jeffrey Segal, MD, JD

The Illinois Supreme Court just overturned damage caps and other medical malpractice reforms adopted in a 2005 reform law.

From The Trenches (Health Care Reform for the Real World) #2: Access Solutions

August 15, 2024February 3, 2010 by Jeffrey Segal, MD, JD

From The Trenches

(Healthcare Reform for the Real World)

#2: Access Solutions

This is the second in a series examining the problems in our health care system from the real world, where patients get sick and injured, and doctors and other health care providers work to heal them. In the series, we’ll identify the actual, non-political problems, and offer sound, sensible solutions that we can enact ourselves to reduce risk and increase patient safety.

Last time, we visited the Nature of the Problem and showed how the advent of the bureaucracy of modern medicine and defensive medicine were causing an access problem. This time, we’ll take a better look at that problem, and present a few variations on practical solutions. We encourage discussion, and hope you’ll weigh in with your thoughts.

In the case study previously mentioned, the patient had Type 2 Diabetes, had acquired a stomach virus and was unable to keep down the oral medication that treated his condition. While it was a legitimate concern that the patient maintain a level of Metformin to control blood glucose levels, the symptoms were not particularly suggestive of H1N1. Since the patient complained only of the vomiting and nausea and concerns about not being able to take his medication, it’s likely that a conservative approach would have been to prescribe Ondansetron to control the vomiting. Instead, because it was a weekend and the patient had no access to his regular physician, the RN line recommended the E.R. That was defensive medicine. Then the E.R. visit itself, which included a simple test to see if he had a flu virus, basic bloodwork, and an EKG (just in case, the otherwise healthy patient is Diabetic, after all,) and a bag hung to rehydrate. An hour or two in the E.R. on a slow evening, and $2600 later, the patient walks out with a script for Ondansetron and instructions to return if symptoms don’t improve within a couple days.

Female Asian doctor looking off to the side

State of the Nation – President Asks Us How To Improve

September 17, 2024January 29, 2010 by Jeffrey Segal, MD, JD

Wednesday evening, President Obama gave his State of the Union address. He was poised, well-spoken, and charming (as usual) as he expressed his expectations that Congress focus on leading, rather than politics as usual. He chastised the U.S. Supreme Court for their decision to allow corporations, especially foreign ones, the 1st Amendment rights usually provided only to citizens and individuals. When it came to the issue of healthcare, though we agree wholeheartedly with what he said about gathering ideas from anyone, we must take exception to his statement overall.

Regarding Healthcare reform, the President said “I want everyone to take another look at the plan we’ve proposed. There’s a reason why many doctors, nurses and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop Medicare abuses, let me know. Let me know. Let me know. I’m eager to see it.”

Mr. President, while many might agree with you that what is proposed could be better than the status quo, MOST doctors, nurses and healthcare experts would say that crucial aspects are decidedly lacking. We must concur with Senator-Elect Scott Brown that we can do better. The unfortunate fact, the reality, is that we have been trying desperately to convince you and the Congress that Tort Reforms are essential and foundational to any real change. We have been trying to tell you that the 60-year old Anti-Trust exemption that medical insurance carriers have been enjoying must be repealed. We have been trying to tell you that granting physicians immunity from medical malpractice suits so long as their actions are within standard procedure guidelines established by the medical community would improve the quality of care while lowering costs. But in each of these crucial aspects, you and Congress have both turned a deaf ear.

From The Trenches (Health Care Reform for the Real World) #1: Nature of the Problem

August 15, 2024January 25, 2010 by Jeffrey Segal, MD, JD

From The Trenches

(Healthcare Reform for the Real World)

#1: Nature of the Problem

This begins a series of examination of the problems in our health care system from the real world where patients get sick and injured, and doctors and other health care providers work to heal them. In the series, we’ll identify the actual non-political problems, and offer sound, sensible solutions that we can enact ourselves to reduce risk and increase patient safety.

Some 35-40 years ago, people would see a physician PRN — as needed. They’d call up and go in to the doctor’s office, and wait to be seen. If there was an emergency, that person would go ahead of the others, so anyone who had need of urgent care would be tended to. If it was after hours or on the weekend, the answering service would patch you through to your doctor, or the doctor who was “on call,” taking care of his patients while he or she was away or unavailable. You’d explain the symptoms, the doctor would then either say it could wait for an appointment, tell you to go to the pharmacy to pick up the prescription he/she called in, or meet you at the hospital if that was necessary. My family physician didn’t have front OR back office staff. A surgeon and surgical nurse instructor, yet he had no need of staff to take care of his patients. And that was in Chicago, in the 1970’s. It stayed that way until about 20 or so years ago, and the system worked well. Then the trouble started.

Follow The Money – Medical Justice Is Still Your Best Bet

August 15, 2024January 21, 2010 by Jeffrey Segal, MD, JD

By now most of you know that Brown won Kennedy’s seat, so the Democrats can’t avoid a filibuster anymore. In the aftermath of this election, there will be a lot of speculation as to whether health care reform is dead in the water. What’s clear is that the last year has been largely wasted. Even today, Pelosi’s House won’t pass the Senate bill (and visa versa.) Perhaps they’ll come together to accept a bill that gives everyone who has a seat at the table some of what they want. But that table still consists of just two sides: Democrats and Republicans. Health Care providers aren’t seated, and most of the world isn’t even allowed to listen in on the conversations.

If Senator-elect Brown wants to walk the talk, perhaps he can push to provide us with transparency by keeping us all informed of what’s really going on. Maybe the new Massachusetts senator can make the rest of the legislature open the doors and let us in on what they’re doing for us, with our money and in our names. Brown ran as a Republican, but spoke as an Independent in his acceptance speech. That would be a pleasant change — someone who votes on the merit of the item, rather than by party line.

Will Scott Brown’s Win Push Democrat’s Health Care Reform Bill Through?

August 15, 2024January 20, 2010 by Jeffrey Segal, MD, JD

Last night, Scott Brown (R, MA) won the election to take the Lion of the Senate’s seat, making it theoretically possible for the Republicans to stage a filibuster. Considering how ill-formed the current Congressional Health Care Reform bills are, and how outspoken the new Senator has been in his opposition to that poor legislation, it’s clear that he and his fellow Republicans will do everything they can to stop the current bills from arriving at President Obama’s desk for signature. Hurray!? Uhm, no. It’s still about two weeks too soon to be cheering.

Some Democratic leaders have hinted that they’ll try to push through their hodgepodge legislation; that they’re bound and determined to “win” by getting healthcare reform enacted. Those who feel the current health care bill is a bad idea are hoping that Scott Brown’s win will save the day, keeping that misbegotten alleged health care reform bill from being crammed down their throats.

The reality? That hope may not be the likely result.

Fearing Filibuster, Democrats Try To Push Through Half-Baked Bill

August 15, 2024January 19, 2010 by Jeffrey Segal, MD, JD

The Healthcare Reform Bill That Never Was

It has been announced that the Democratic Congress is trying to push through their unfinished and unmerged concepts of what they call healthcare reform, even though neither of the bills is complete and proper melding of the two is a long ways off. Why? Because there’s a good chance that a Republican will take over Kennedy’s seat, allowing for a filibuster. Seems like a reasonable strategy for a politician, but what would it do for We The People?

What it would do is worse than doing nothing. Though they’ve had a year to pull it together, this haphazard set of political concessions lacks a unifying vision, a comprehensive functional approach. Even now, the House and Senate bills are incompatible. To jot down something, cut and paste all that rhetoric into one bill and force it through (and down the constituents’ throats) instead of allowing the Republicans the opportunity to have their say in the matter (whether by filibuster or otherwise) is just petty politics and ought to be beneath men and women of integrity.

But why is it worse than nothing? Glad you asked. Most people don’t yet realize it, but the taxes will be imposed upon the people immediately, even though the benefits of the bill won’t kick in for a minimum of three years. Yep. We’d be paying for this half-baked brain-flop and still be on our own with the status quo for three (and most likely several more) years. It’s nothing short of childish to push an unfinished bill through just so the other side of The Aisle can’t participate in what some still jokingly refer to as the Democratic Process.

Drug Manufacturers Back For a Second (Make that Third) Helping At Healthcare Reform Table

August 15, 2024January 17, 2010 by Jeffrey Segal, MD, JD

It seems they’re all coming out of the woodwork, demanding something in exchange for supporting the proposed health Care Reform bills. The drug companies are just the latest to announce that they “won’t be able to support” the bill unless it provides them with twelve years of exclusivity for expensive prescription drugs. (Since when do all of these Special Interest groups even have a say in the matter? Just sell your products as best you can on the open market!) In the final moments before the vote, at least one state was promised that the Federal Government would pay all the increases in Medicare costs for their state — forever — if their representative would vote in favor of the bill. Then, before that… oh, wait, that was the drug companies again.

Wasn’t it the drug companies who had just raised prices in anticipation of more windfall profits from all the newly insured? There was even an article in some big-city paper about it, and how it was the same way once before, when Medicare was expanded or somesuch. But isn’t it poor form to go back for seconds before everyone has had their first helpings?

Sure, companies are for-profit. Can’t very well blame them for trying to do what they’re built to do, can we? Then again, there’s another saying: “I don’t mind you making a profit, but do you have to make it all on me?!”

Calling Out Burris; Senator Roland Burris Offers Weak and Inaccurate Excuses In Lieu of Tort Reforms

August 15, 2024January 14, 2010 by Jeffrey Segal, MD, JD

One would think a junior Senator who was appointed by an ousted Governor to take President Obama’s vacated seat would realize that he needs to be a quick study and know what he’s talking about — especially since he’s made four unsuccessful bids at being voted into public office. One would think that the subject of Tort Reform would be on the mind of one of the two senators to represent a state as influential as Illinois. One would think Senator Burris would be able to get the material facts straight. Unfortunately, though he’s one of the 100 votes, it would seem the appointed incumbent remains largely and disappointingly clueless on the subject of Tort Reform, an essential aspect of Health care Reform.

I wrote Senator Burris as a private citizen, expressing my concerns about the upcoming Health Care Reform vote, and the need for Tort Reform within that legislation. His reply is decidedly lacking in substance:

“Medical malpractice lawsuits serve as an important method of recouping lost income, medical expenses, and restitution for pain and suffering in cases where a physician, hospital, or other health provider acts negligently. A person who suffers debilitating injury, due to misconduct, deserves an avenue to seek justice. Our great legal tradition dictates that a jury of peers makes determinations of this kind.”

No one would argue against the idea that a patient who was actually injured by negligence should be compensated. Unfortunately, the Senator is suggesting that this is a binary issue; Burris is essentially saying that we must either allow no law suits at all, or allow any fool with filing fees to sue anyone at any time without cause. No one is suggesting that we abolish all avenues to seek justice. What we are saying is that the system itself should be just; and not impose unnecessary and unfair burdens upon doctors and other health care professionals. What the senator chooses to ignore is that the current system is largely open season on doctors, and anyone and everyone gets to take a pot-shot at them, in hopes of hitting a jackpot. We’re not trying to get rid of all lawsuits against physicians, just working towards improving the system so that it is more honest and fair, so that doctors don’t have to stop everything and spend small fortunes to defend against every greedy jackpot lawyer in the country. That’s why we call it tort REFORM, Senator, not prohibition.

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