Bcbs Wellness Card Reimbursement: Fill & Download for Free

As a U.S. citizen who was born and grew up in Taiwan, I’ve been asked the pros and cons in the healthcare systems in Taiwan and U.S. Here are my analysis:U.S. Healthcare System: Employment-basedIn U.S., most people choose healthcare plans through their employers. The majority of these employment-based plans are managed by private insurance companies like Blue Shield and Blue Cross and UnitedHealth Group that provide medical services through Preferred Provider Organizations (PPO). Employees can also select Health Maintenance Organization (HMO) plans managed by large hospital systems such as Kaiser Permanente and Geisinger. Operating like Walmart, these HMOs provide medical services in one-stop-shop style so that patients can see the doctors, get lab tests, and obtain their prescription in the same medical building. You can learn more about how PPO and HMO provide and manage their services in my article “HMO vs. PPO”Strengths:Companies include healthcare plans as parts of their benefit packageCompanies compete for and retain top talents with their benefit packages, and what most candidates look for in their offers are the health care plans for their families and themselves.Because of the numbers of their beneficiaries, companies have stronger bargaining power than individuals on getting ideal healthcare plans. Therefore, employment-based/company-run healthcare plans are much better than the plans in the individual/select markets.When my husband told me that he wanted to pursue a better opportunity, the first thing I immediately asked was “What type of insurances can we get through your new company?.” I was reluctant to let him leave Apple because I had been spoiled by Apple’s UnitedHealth Group health plan. Never had I been answered by a real human when I called the 1–800-numbers on the back of my insurance card until my husband worked in Apple. In addition, I would not be able to afford my hip surgery without Apple’s help. Thankfully, Shane’s current boss kindly offered another good plan. Otherwise, my husband would not be able to pursue his dream job just because there was no ideal healthcare for our family.Patients are responsible for their own healthcare plansPeople have to think about the types of medical services they need when they consider new healthcare plans. For examples, they should seek free or affordable vaccination plans if they just have a new baby or annual check to maintain their health. Allowing people to plan their own healthcare spending prevents people seeking unnecessary medical services.You get the most advanced medical therapies and medicine in the worldBecause the U.S. healthcare system is run by capitalism and the capitalism awards creativity, you can find almost all the most advanced medical therapies and medicine in U.S.; pharmaceutical and medical companies are awarded with lucrative money and fame when they introduce new drugs or innovative devices. Patients can receive the best medicine and the most innovative therapies if they can afford it.Weaknesses:The current healthcare plans in the markets are getting too expensive and complexI often say selecting a good healthcare plan is as challenging as finding a good spouse: you never know if the plan will change later and how expensive it can get. Not only would you have to budget for the medical spending but also understand the definitions of those insurance items such as deductibles, co-insurance, and co-pay. In addition, private insurance payers/insurance companies and providers/physicians/clinics continuously create new plans (e.g. “group plans”) and tactics (e.g. reimbursement modifiers) to control medical spending. In addition, private insurance companies keep creating new healthcare plans like POS and FOS and yet not many people can differentiate these plans.Your medical spending can be very expensive just because of “one medical incident”There is no absolute safety net in U.S. healthcare system. One medical incident, whether a fall from the stairs or a car accident, can potentially get you bankrupt. It is primary because there are many untold rules printed in the small font behind the confusing reimbursement terms like co-pay, co-insurance. I am very grateful for Apple’s health care plan, because no other plans would allow me to pay only $500 to over my $200,000 hip surgery.No job, no ideal or affordable health planWhen you are unemployed, you have these choices:COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): Offered by your previous employer for a short period of time.Individual healthcare plans in the individual/select market: Offered through ACA (Affordable Care Act/Obamacare).Medicaid, if you are low-incomeMedicare, if you are a 65-year-old or older seniorCHIP (Children's Health Insurance Program), if you are low income with young childrenYour parent’s healthcare plans, if you are younger than 26.(Note. Medicare, Medicaid, and CHIPs are managed by the Centers for Medicare & Medicaid Services, or CMS)These plans are either very expensive or not ideal, and medical expenses add on relatively quickly when you have chronic diseases or complicated medical conditions. In addition, you will have to combat many bureaucratic hassles, such as shortage of doctors and delay in getting medical reimbursement. Things especially get worse when you have a public healthcare plan like Medicaid and Medicare, especially the federal and state governments continuously reduce the budget.When a family member told me he planned to stop paying for the private plan included in his pension, I immediately jumped from the chair to stop him from doing so. Medicare itself could not cover his prescription and the physicians he preferred to see. Its “Donut Hole” and long-wait on getting basic medical procedures have been torturing many Medicare beneficiaries so the last thing I wanted was seeing my family become one of the victims. I am still glad the family member still pays for both his Medicare and BCBS plan.Not everyone is capable of managing his/her healthcare planWithout basic medical and financial knowledge, it could be relatively difficult for one to manage his/her own health care plan. Otherwise, we would not keep seeing ones go to emergency rooms for a cold that just takes a few days of rest, or people with diabetes eating carbohydrate-enriched food. The good means of allowing everyone manage his/her health plan with freedom are quickly diminished without providing the general public basic information on finance and health care management. The lack of transparency on the prices of medical services worsens the situation.Your medical coverage are determined by financial professionals, not medical doctorsThe private insurance companies are incentivized to reduce medical spending in order to increase its profit. After all, they are financial institutes responsible for their stockholders, not your health, which was much hard to predict and control. It is the open secret that your medical coverage is determined by financial, not medical, professionals. Since these financial professionals are responsible for the company’s performance in the stock market next 12 months, why would they care if cutting off your high blood pressure medicine would induce your stroke in five years, which would definitely be more expensive and complicated to fix…At the same time, physicians and hospitals are incentivized to order more medical tests or increase the unit prices of their services.The Fee-For-Service (FFS) Reimbursement system in most, almost all, healthcare systems worsens the situation. Physicians and hospitals are paid based on the amount, not the quality, of the medical services they order and provide. In order to get more reimbursement from the insurance companies, which is equivalent to the revenue, hospitals and physicians tend to prescribe unnecessary services (of course, they do so also to protect themselves from any malpractice sues, which is another topic to discuss) or increase the unit price of each medical items. Hospitals and clinics hope to get more reimbursements when they submit the bills to the insurance companies (both private insurance and CMS).Patients are responsible for paying the difference between what the providers/physicians/hospitals/clinics ask for and what the insurance companies reimburse forProviders (e.g. physicians, hospitals, and clinics) and payers (e.g. private healthcare companies and CMS) sign contracts every year to decide how much payers will pay/reimburse for how much providers ask. Usually, it is the percentage of reimbursement asked by the providers. Patients are responsible for paying the difference between what the providers ask for and what the payers want to pay.For example, if you decided to go to an emergency room (ER) for your upset stomach :Step 1: You would definitely receive some medical services and physician visits when you went to the ER. By laws, all ERs must admit you regardless your conditions.Step 2: The ER’s hospital would submit your bills to your payers (a.k.a. the companies you purchased your health care plans from). Most providers would usually ask for 1.2 times or more of the unit price of each medical item determined by the CMS.Step 3: Your payer would pay the hospital based on the contract it signed with the hospital and your plan (i.e. what your deductibles/co-insurance/co-pay were…). The percentage the payer was willing to pay for the hospital was called “discount rate.”Step 4: The hospital would decide whether they wanted to collect the difference between what it asked for and what your payer paid. Most of the time, i would.Therefore, you would have to pay the hospital $300 because:The hospital asked for $2,000.The payer paid the hospital $1,500 because the discounted rate on the contract between the hospital and the payer was 75%Your payer would also cover addition $200 because your plan’s co-insurance rate was 40%Your annual deductible was $2,000 and you hadn’t paid any medical cost out of your own pocket before your ER visit.Well, there might be more bills for you to take care. Somehow, the physician who you saw in the ER was a doctor with his own clinic and was a contract staff in the hospital. The lab test you got was managed by a third-party company. In this case, you might get two additional bills - one from the physician and one from the third-party - after you paid off your hospital bill. Use the same formula to figure out the money you would have to pay for the physician and the lab test.Therefore, the U.S. health care spending accounts for 17.9 % of U.S. GDP in 2018Under the FFS system, the physicians and hospitals will keep order more medical services or increase their unit prices when the health care insurance companies keep creating ways (e.g. reimbursement modifiers) to stop paying for them. More and more money are wasted on administration and financial analysis rather than improving the operational effectiveness or accuracy in the clinical setting. This unpleasant development is not only devastating to the patients and health care plan beneficiaries but also drains the country’s economic competitivenessTaiwan Healthcare System: UniversalIn 1995, the Taiwan Central Government established the National Health Insurance (NHI), a single-payer healthcare system that benefits all Taiwanese people, especially ones with socioeconomic disadvantage. NHI has helped Taiwan improve its public health since it existed, and it is managed by the National Health Insurance Administration under the Central Government’s Ministry of Health and Welfare.Strengths:Easy access to basic medicare careInfant mortality and morbidity in Taiwan has dropped after the NHI was implemented in 1995, primary because the moms can easily receive affordable prenatal care and bring their babies for free vaccination. Chronic diseases are managed more effectively because patients are encouraged to seek for preventative care.Affordable medical procedures required to cure and manage chronic and complex diseases.Under the NHI system, curing rare diseases is affordable and convenient in Taiwan. Patients can focus more on working with the medical staff on managing their diseases than on paying for medicine and therapies. Medical services, physician visits, and therapeutic drugs are priced fairly.Taiwan offers the cheapest and one of the best medical facilities of any country in the worldThe top three medical services in the world are offered in U.S., Germany, and Taiwan. In addition, the medical facilities in Taiwan are the cheapest. Taiwan has the best doctors in the world because getting into a top medical schools is still the No. 1 choice to the most intelligent high school students. This trend is a historic consequence. Before the end of World War II, Taiwan was controlled by the Japanese government, and medicine and teaching were the only two professions the smartest Taiwanese people were allowed to study. Such circumstance existed in most colonies because the last thing the empire wanted was allowing natives to become politicians or independent thinkers. Natives were still allowed to teach and practice medicine. because healthcare and educations are the necessity to stabilize the society.Though World War II ended decades ago and more and more Taiwanese people choose other professions like engineering, the brainiest people are still encouraged to study medicine. Therefore, Taiwan has the best preventative medicine and therapies to cure cancer, rare diseases, and chronic conditions.Weaknesses:NHI is going bankruptSadly, the good meaning of providing everyone affordable care has been abused by many Taiwanese people who just want to take things for granted. Many visit doctors for unnecessary conditions or take extra drugs just because they are free. In addition, they prefer to attend Level 1 hospitals instead of local clinics for minor colds or stomach problems just because the Level 1 hospitals sounds more prestigious and authentic. Again, any good healthcare system should be accompanied with basic financial and medical knowledge to the patients in order to operate sustainably.Years ago, the Taiwan Central Government implemented NHI Guidelines 2.0 to hopefully control the unnecessary medical waste. Nevertheless, without providing the general public education on medical spending, many Taiwanese people still wastefully leverage the medical resources in Taiwan that are too affordable.National Health Insurance Administration (NHIA) is shifting its finance burden to the hospitals and clinics.Instead of educating the general public how valuable medical resources are, Taiwan’s NHIA chooses to control the medical spending by reducing its reimbursement to the medical providers (e.g. hospitals and clinics) and suppliers (e.g. pharmaceutical and medical device companies) for political reasons. Such a practice causes medical scarcity, primary because:In order to balance the reduced revenue, the hospitals and clinics choose to compensate their medical staff less or increase the physician:patient (or nurse:patient) ratios. More and more salary-based medical team members, especially nurses, work overtime without proper payment. Thankfully, Taiwan is a socialist country so almost all Taiwanese medical staff still put patient well-being before their compensation. Nevertheless, it is not a long-term solution.The shortage of the medical doctors in five medical disciplines. More and more medical school graduates choose not to practice medicine in internal medicine, surgery, OB/GYN, pediatric medicine, and emergency medicine. Instead, they pursue to become dermatologists or chiropractors. They do so for two reasons:Under National Health Insurance Administration’s guidelines, performing a CPR is not as expensive as applying botox.Being a dermatologist is less risky and more profitable than a surgeon. Surgeons conduct higher risky and challenging medical procedures such as open heart surgeries. Their life style are very hectic and not family-friendly.The shortage of medical services in rural area. Hospitals need to provide certain amounts of medical services in order to stay profitable. However, rural populations continue to decline and more people move to the cities, which force more hospitals to close their business in the rural areas.More international pharmaceutical and medical companies refuse to export their products to Taiwan, because the reimbursement they receive from NHIA can not cost their operation costs.Conclusion: It is time to revamp the reimbursement systems in all healthcare systemsBoth Taiwan and U.S. healthcare systems face challenges in staying sustainable because the major stakeholders fight against each other in the preposterous Fee-For-Service (FFS) reimbursement system. Physicians and hospitals are incentivized to conduct medical procedures as many as possible in order to attain more revenue from the insurance companies, even if some procedures are unnecessary. On the other hand, payers, or the healthcare insurance companies, are hiring more financial professionals to analyze ways to avoid payments.Even the current Mayor of Taipei, Dr. Wen-Je Ko, argues FFS is not substantial. Dr. Ko established the Integrated Care Unit at National Taiwan University Hospital to treat patients with complication. Unlike most hospital units, Dr. Ko recruited and staffed the best physicians, nurses, and pharmacists in his ICU in order to treat patients like teams. The pharmacist would provide the patient prescription and the nurses would conduct the medical procedures immediately after the physician ordered the tests and medicine.Nevertheless, it was ironic Dr. Ko’s ICU was the least profitable unit in National Taiwan University Hospital even though it had the highest patient satisfaction, performance outcome, and operational efficiency. Dr. Ko’s ICU ordered far less medical tests because the staffed physicians, unlike most residents, could quickly make accurate diagnoses without ordering too many tests.Like President Obama, Dr. Ko advocates for transforming the reimbursement method from FFS to value-base method. Unfortunately, it is relatively difficult to “price-tag” the medical services based on how well the patients recover.First, it is not easy to quantitatively evaluate the price of many qualitative medical services. For example, how do you evaluate physician’s visits that somehow helped the patients improve their conditions without medicine.Second, it can be relatively difficult to ask professionals in different disciplines, especially ones functioning in silos, to work together. Many physician and medical staff are unable to connect financial values to their performance. On the other hand, accountants and medical economists might not understand why fewer medical care could deliver better medical outcomes.Third, how do you evaluate a physician’s performance in different clinical settings? Patients often have different outcomes while being treated by the same physician but in different hospitals.Fourth, the regulatory and bureaucratic restrains hinder changes in the healthcare system, including revamping the reimbursement methods. It is not easy to share the medical records because patient privacy is protected by Health Insurance Portability and Accountability Act (HIPPA) and the scale and complexity of teamwork eventually build up the bureaucracy.President Obama once said he admired the efficiency and efficacy of Taiwanese Healthcare System and yet Taiwanese NHI is on the edge of bankruptcy. I very much hope we can hybrid the goods in the U.S. and Taiwan health care system with today’s technology, patient’s education, and reimbursement transformation to achieve the goal of “providing everyone, especially the people with socioeconomic disadvantage, equal access to the basic healthcare.”