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Health care costs affect the economy, the federal budget, and virtually every American family’s financial well-being. Health insurance enables children to excel at school, adults to work more productively, and Americans of all ages to live longer and healthier lives. The Affordable Care Act (ACA), has made substantial progress in addressing the uninsured Americans. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control.There are several companies which provide health insurance to the US citizens under the ACA, which in-turn promotes Medicaid and Medicare government programs. According to these programs and their respective market shares, the best positioned health insurers are:-UnitedHealth Group Inc.Humana Group Inc.Anthem Inc.These insurers have been working in developing a high-quality, affordable and accessible health care system.In this answer, I will be assessing the progress these companies have made towards improving the US health care system and discuss how policy makers can build on that progress especially under the Trump administration.Medicare ProgramMedicare is a national social insurance program administered by the US federal government since 1966, currently using about 30–50 private insurance companies across the United States under contract for administration.UnitedHealth Group Inc. provides mainly three plans under the Medicare program.Medicare Part A (hospital)Medicare Part B (doctor and out-patient)Medicare Part C, a type of health plan ,also known as Medicare Advantage Plan. This plan combines the Medicare Part A and Medicare Part B, then provide additional benefits that contribute to improving your health and wellness.It also provides other Medicare Advantage plans which include prescription drug coverage (Medicare Part D). Enrollment in Medicare Part A and Medicare Part B is necessary to be eligible to enroll in this plan. It is necessary to continue paying your Medicare Part B premium to keep your coverage under this group-sponsored plan. UnitedHealth tries to offer coverage that is as good as Original Medicare. The government pays them a fixed fee for one’s care. UnitedHealth is required to handle the payments to doctors and hospitals.Humana Group offers the Medicare Savings Program (MSP) to Medicare beneficiaries whose income falls below $1,357 per month for single individuals and $1,823 per month for married couples.Humana offers several other plans under Medicare, one of which is the Humana Gold Choice plan. Humana Gold Choice is a Medicare Advantage private fee-for-service (PFFS) plan. Humana Gold Choice PFFS allows members to use any provider, such as a physician, hospital or any other Medicare provider in the US that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B or eligible to be paid by Humana Gold Choice PFFS for benefits that are not covered under Original Medicare.Anthem Inc. (Wellpoint Inc. Group) has been focusing on making sure that the needs of the people under the Medicare Program are addressed.Anthem has health plans that support those who are Medicare eligible by developing HMOs and PPOs specific to Medicare and providing Medicare Supplement plans to those who want them. They have been constantly working on expanding the tele-health options.Consumers’ costs concerns are addressed with Dual-Eligible Special Needs Plans (DSNPs) that are primarily $0 premium plans with $0 copays. They include dental and vision coverage and some even include coverage for over-the-counter drug costs. HMOs and PPOs specifically focused on accommodating the needs of the Medicare population are now available in targeted markets in 22 states. In specific markets in California and Texas, Anthem’s Medicare Select plans feature tight-knit provider collaboration. Also, convenient online doctor visits are available to most of Anthem’s affiliated Medicare Advantage plans through LiveHealth Online.Medicaid ProgramMedicaid in the United States is a social health care program for families and individuals with limited resources. Medicaid coverage is low cost or no cost to you. It is health care coverage for people with low incomes. Pregnant women, children, the elderly and people with a disability may qualify for the Medicaid Program.Medicaid Program discussed below is in reference with the state of Florida.UnitedHealth Group Inc. With growth in the Medicaid market, UnitedHealth took a vital step of launching a mobile app to better connect with people covered by the state-federal health insurance program.The new app called ‘Health4Me’ lets people in the state of Florida use their phones to more easily review their case history, track claims and find a doctor. The app also provides a digital health plan ID card, which has proved to be the most popular feature in early testing. It’s more about improving the way we share information than anything else when we decided to launch this for our Medicaid population.Expansion of Medicaid eligibility due to the federal health law has been a key factor in enrollment growth across the country, although some states have elected not to expand their programs. In 2014, about 5.1 million individuals were covered through Medicaid health plans at UnitedHealth and during the first half of 2015, the figure grew by 155,000.Humana Group has offered Medicaid services since 1970 in Florida. It is funded by both the state and federal governments and includes both capitated health plans as well as fee-for-service coverage. The Agency for Health Care Administration (AHCA) is responsible for administering the Medicaid program and to administer contracts, monitor Health Plan performance and provide oversight in all aspects of Health Plan operations. The state has sole authority for determining eligibility for Medicaid and whether Medicaid recipients are required to enroll in, may volunteer to enroll in, may not enroll in a Medicaid health plan or are subject to annual enrollment. The 2011 Florida Legislature passed House Bill 7107 to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services. This program is referred to as the Statewide Medicaid Managed Care (SMMC). In addition, Humana has the responsibility to ensure providers’ submission of encounter data is accepted by the Florida Medicaid Management Information System and/or the State’s encounter data warehouse.The Florida Managed Medical Assistance (FMMA) program focuses on four key objectives in order to support successful implementation:Preserving continuity of care.Requiring sufficient and accurate networks under contract and taking patients, allowing for an informed choice of plans for recipients and the ability to make appointments.Paying providers fully and promptly to preclude provider cash flow or payroll issues, and to give providers ample opportunity to learn and understand the plan’s prior authorization procedures.Coordinating with the Choice Counseling Call Center and website operated by the Agency’s contracted enrollment broker.Anthem Inc. has been investing significant time and resources to understand and serve the nearly 5.9 million plan members in state-sponsored programs across the country. While focusing on the needs of individual consumers, our plans are seeking out new and better ways to improve health outcomes with high-quality, cost-efficient programs that help society more broadly.Florida ranks first in the nation in the number of newly diagnosed HIV infections and second in the number of pediatric HIV cases reported. Clear Health Alliance, an HIV/AIDS Medicaid specialty plan offered by Simply Healthcare Plans, is addressing the special needs of those living with HIV/AIDS in Florida by offering bundled services tailored to their treatment requirements. Anthem is equipping consumers with the knowledge and support to better manage their health.Commercial Business ModelsUnitedHealth Group Inc.The UnitedHealth Group is a leading diversified health and well-being company that provides health benefits and health services through UnitedHealth and Optum business segments. UnitedHealth provides health benefits services to individual consumers, governments, and employers of all sizes. Optum offers health services to diverse stakeholder groups that include individuals, employers, governments, healthcare providers, payers, and life sciences companies.UnitedHealth Group Business Model EvolutionThe chart shown below is a one year stock market analysis till January 2017.The Insurance Company saw an enormous rise in the revenues and made a large operating profit.Humana Group Inc.Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014 Humana has had over 13 million customers in the U.S. reported a 2013 revenue of US$41.3 billion and has had over 52,000 employees. It has been the third largest health insurance in the nation.Following is the Financial Highlights of Humana Inc. The results have been extremely supreme over the years!Stock market of Humana Inc. over the last year:Anthem Inc.Anthem Inc. is an American health insurance company founded in the 1940s, prior to 2014 known as WellPoint, Inc. It is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association. It was formed when Anthem Insurance Company acquired WellPoint Health Networks, Inc. with the combined company adopting the name WellPoint, Inc. trading on the NYSE for the combined company began under the WLP symbol on December 1, 2004. On December 3, 2014, WellPoint changed its corporate name to Anthem Inc, and its NYSE ticker changed from WLP to ANTM.Financial Highlights of Anthem Inc. for the past years:Financial and Membership Highlights:(The information presented below is as reported in Anthem’s 2015 Annual Report.)Data Sources:How UnitedHealth Group Makes Money? - Revenues & ProfitsUnitedHealthcare launches Medicaid AppHumana Medicare and Medicaid InformationAnthem, Inc | Investor Relations | Annual ReportsAnthem Annual ReportMedicaid - WikipediaMedicare - WikipediaImage SourcesUnitedHealth Group Incorporated (UNH) Stock ChartGoogleGoogle Images2015 Annual Review UHC

Will Ayushman Bharat help BJP win the 2019 elections?Answer requested.It may, as this scheme itself seems to have been worked out on paper precisely for the same purpose with an eye on the ensuing general elections. Of course, all political parties always try to pull such stunts in an election year, and therefore let us brush it aside for the moment, and see how effective this can be in the implementation at the ground level. I will be quoting excerpts from two articles to see how those in the know seem to feel about this scheme.It may be recalled that PMJAY is one of the two components of Ayushman Bharat, the Modi government’s flagship health initiative. The other component is the creation of 1,50,000 “health and wellness centres”. The finance minister allocated Rs 1,200 crore for these centres in 2018-19. That comes to Rs 80,000 per centre. Essentially, it is just a new coat of paint for the old primary health centres, which are being renamed for the occasion.The budget allocation for PMJAY in 2018-19 is just Rs 2,000 crore. That is not much more than the previous year’s budget allocation of Rs 1,000 crore for Rashtriya Swasthya Bima Yojana, PMJAY’s predecessor, which is now being subsumed under PMJAY. In other words, there is virtually no new money this year for PMJAY.The government claims that PMJAY will provide a health insurance cover of Rs 5 lakh to 10 crore families (about 50 crore persons). What would it actually take to provide this sort of insurance cover? If the beneficiaries spend just one per cent of their Rs 5 lakh quota in a year, on average, then the annual expenditure will come to Rs 50,000 crore. This a very conservative estimate – if the scheme makes it reasonably easy for people to claim their insurance money, the actual cost could easily be twice as much, or more. There is absolutely no indication that the government is willing to spend that sort of money on PMJAY.According to recent media reports, NITI Aayog experts anticipate the annual PMJAY budget to rise to Rs 10,000 crore or so in the next few years, or something in that range. But Rs 10,000 crore (more than five times the current PMJAY budget) is still chickenfeed for the purpose of providing health insurance to 10 crore families. It comes to Rs 1,000 per family, or Rs 200 per person. For the whole year.How would you feel if you were told you that your budget for health care this year is Rs 200? An illusion has been created that putting this money in an insurance premium has some sort of multiplier effect. This is not the case at all. Insurance can help to redistribute health expenditure towards those who need it most, but it cannot turn Rs 200 into more. If the government spends only Rs 200 per person on health insurance, that’s the amount of health care an average person gets, that too assuming that there are no transaction costs.Nevertheless, PMJAY is being projected as “the world’s largest government funded health care programme”, as the finance minister put it in his budget speech. This is very misleading. The term “largest” presumably refers to the proposed population coverage of 50 crore or so, but the wide coverage is achieved by reducing per-capita expenditure to a microscopic level. And even the coverage is not the largest in the world: China’s health care system, with its universal coverage, is much larger. In per-capita terms, public expenditure on health in China is about five times higher than in India.I suspect that PMJAY actually has little to do with health care, for the time being at least. The real purpose, judging from the National Health Stack documents, seems to be to enable private players to harvest huge amounts of health-related data. It is another instance of what the wizards of information technology call “creating public platforms” (on the back of government schemes) that can be used to develop profitable applications. If that is the purpose, then it makes perfect sense to maximise the coverage and minimise expenditure per person. Maximising coverage, of course, is also a good strategy for the purpose of winning votes.Ayushman Bharat Trivialises India’s Quest for Universal Health CareOf course I already hear a distant chorus about how Jean Dreze is an Urban Naxal and The Wire is a heavily left leaning publication with an anti-Government bias. I agree, and even see some oversimplifications in the entire calculation. So, instead of harping on this,Please point out the logical fallacies if any in the article’s conclusion, and show how the Government plans to actually and practically implement this scheme at the ground level in a meaningful debate.Meanwhile, I will show you another article echoing almost the same sentiment.Dr Avinasi Kandasamy Ravikumar, national coordinator, insurance, at the Indian Medical Association -- which is described as 'a national voluntary organisation of doctors of modern scientific system of medicine in India, which looks after the interest of doctors as well as the well being of the community at large -- explains to Rediff.com's Prasanna D Zore why the cost of treating a patient under Ayushman Bharat will punish patients by making them travel longer distances to obtain healthcare and kill smaller and medium-sized hospitals that will be empanelled under this scheme.What, according to you, should the government do to ensure that Ayushman Bharat is a success?The government must ensure that the service providers (hospitals) are made to feel comfortable by mandating a comfortable package rate.The scheme will be very successful only if empanelled hospitals are comfortable delivering the goods under the NHPS.According to your scientific study what cost of the procedures/operations stated above could make the service providers feel comfortable?Let me just give you one illustration: For a caesarean operation, the scientific cost derived at by us after following all the government mandated norms comes out to Rs 57,515.This includes: Pharmacy cost (Rs 7,619), consumable cost (Rs 1,228), investigation cost with details (Rs 2,610), doctors and nurses’ fees (Rs 15,000), other employees’ cost (Rs 11,061), accommodation cost (Rs 9,572), medical equipment usage cost (Rs 5,348), maintenance cost (Rs 1,098), and administrative cost (Rs 3,979).In this case then, will Ayushman Bharat achieve the goals it has set out for itself?It's just not possible! Unless the service providers are comfortable and they extend their hands, the programme will be a failure.Who will be the biggest gainers and losers of the Ayushman Bharat scheme?If they (the government) are going to route the payments through the insurance companies, then these companies will be making nearly 30 per cent of the money.For instance, if the government is paying Rs 100, then Rs 30 will go to these insurance companies to cover their cost of operations.Only Rs 70 will be available for other expenditure that will be incurred by the hospitals.As far as the Indian Medical Association is concerned, we feel the government should take the 'trust' model -- to route payments to the hospitals through a government trust -- instead of the insurance companies.Insurance companies are like middlemen. Naturally any business intermediary is in it to make money.We don't want that to happen so that this money (Rs 30 out of every Rs 100 that will go to the insurance companies) can be diverted for the benefit of the patient through the service providers.Definitely, the biggest gainers would be the insurance companies and hospitals/service providers will be the biggest losers.Ayushman Bharat is one of Prime Minister Modi's dream projects.That's what I am saying. The scheme is very good, but the methodology by which the rates have been fixed will not make the service providers happy.The main part is the monetary part and that is not being taken care of.'Ayushman Bharat will be a big flop'(Italics added for emphasis)So, to revert to the original question, without denying the utmost importance of a scheme to ensure universal health care especially to the economically disadvantaged sections of the population, or the present government’s noble intentions in this direction, sadly this scheme in its present stage seems to lack substance without logistical or financial support. Yet this may not deter the hard core supporters of the present ruling dispensation to go on a publicity Blitzkrieg which might still influence some segments of the electorate to vote for the BJP in the 2019 elections, though it must be anybody’s guess if this could ensure a win.“One of the great mistakes is to judge policies and programs by their intentions rather than their results.”― Milton Friedman

“There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president of quality and patient safety at the American Hospital Association.Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why. Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell.Most hospitals don’t have such rules, said Julia Hallisy, a patient safety advocate from California. That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance.…On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said.If that doesn’t pan out, insurance plans may step in.When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment.In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.Patients, Krusing said, shouldn’t pay for what’s out of their control.And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.”https://www.washingtonpost.com/national/health-science/a-medical-mistake-happens-who-pays-the-bill/2015/11/09/9d4f6ee6-78d1-11e5-b9c1-f03c48c96ac2_story.html?noredirect=on&utm_term=.b439954be0b5As to the surgeon’s bill specifically, that would likely more depend on the surgeon and if he believed he truly did do something wrong.Some surgeons DO operate on high-risk patients.Some do it with the knowledge the patient is so far gone odds are good he won’t pull through.BUT your question asks about a MISTAKE which is a different issue.Personally I suspect that most surgeons would NOT charge for a surgery in which they DID make a mistake. However while that sounds good, it can also be debatable if something WERE a mistake or not. There are many surgeries where a decision would have to be made once inside and if a surgeon does not get a good outcome, did he make a “mistake” or it would have been as bad or worse if he’d gone another route? It would be difficult to say in many cases so it’s best to assume barring something like removing the wrong limb, that the patient and any insurance will be charged.