When A Loved One Needs Assistance With Daily Living

While living in a well-run assisted-living or other support of residential living arrangement can provide many positive social, safety and healthcare benefit for patients with declining physical or cognitive abilities, most elderly and disabled individuals dread and resist moving from their home to an assisted living or other supportive care living environment.

When transitioning a patient to an assisted living or other care environment, caregivers often must override and understand what preference by the patient to live independently in order to provide support to patient needs to be safe.

Like the surrender of driving privileges, the loss of choice that results from compulsory relocation to a new living environment for an elderly or disabled person forces the patient concurrently to confront his declining functionality and his declining self-determination.

Recognizing this, caregivers should seek to involve the patient as much as possible in making the new living arrangements.

Talking about the possibility of a future need her assisted living care well in advance at the onset of disabling condition can help.

Planning ahead can help patients and their families to be prepared to pick up a facility where the patient may already have friends for siding will be familiar with the staff or the facility reputation.

Many assisted-living providers also sponsor social or other community out reach events for members of the community living independently.  Others offer daycare or other intermittent care opportunities.  Still others may offer temporary assisted-living or stay arrangements following episodes of chemotherapy or other intensive inpatient care.  Participation in these opportunities for involvement gives a patient an opportunity to try out the facility in their services before the patient actually needs to relocate as well as gives the family and the patient the opportunity to check out the facility before making a choice.

When relocating the patient to an assisted living or other facility, careful planning can help ensure that the patient’s room and other living quarters are as home like as possible.  To the extent that space allows, try to bring to the facility some furniture, photographs and other special possessions that will make the new living space feel more like home.

It often also helps if family members participate in the daily flow of activities such as going to lunch or dinner or participating in social gatherings often on for the first few weeks to help encourage the patient to participate in acclimatize them to the new opportunities and friendships.

The best way to head off problems is to detect issues early and intervene.  Even after the patient as well settled family members and friends should drop by often and at varying times to check on the patient’s physical and emotional status, keep the patient engaged and to check up on the care and service that the patient is receiving.

Family members and friends should learn and watch for signs of abuse or neglect.  Many excellent sources of education and resources are available through state Agency responsible for oversight in care of the aging and disabled like this list of elder neglect warning signs  published by the State of Idaho.

To help safeguard your loved one, make sure you and others with a close relationship to the patient check in on the patient regularly.  Set aside time to check in on the patient as well as to talk to the patient to detect signs of abuse, neglect, deterioration in the patient’s physical, cognitive or emotional status or other signs of possible concern.  Even something so seemingly minor as a recurrent failure at the facility staff timely to assist the patient to make her bed or with other schedule services should be monitored and addressed.  Beyond the actual assistance with the performance of the designated chores, the interactions scheduled with staff to perform these chores are critical monitoring activities for the facility.  Failing to timely perform the services means the facility is not keeping on top of their monitoring and other care duties for the patient and should be addressed.

Be A Healthcare Hero: Join Project COPE

Follow, like and share our articles and resources in this ProjectCOPE.blog, and follow, like, share your comments and ideas, and participate in our Facebook @ProjectCOPECOALITION or on LinkedIn to:

  • Learn tips, tools and other information on how you and your family can manage your health and wellness needs?
  • Get ideas on how to understand, shape and use your healthcare and coverage?
  • Share your ideas and input about health and health coverage issues and policies with elected leaders and regulators?
  • Monitor health, wellness and other developments?
  • Help your providers, family, friends and community cope with health care, disability, aging and wellness challenges?

Despite an endless stream of well-meaning market and governmental reforms over the past 25 years, the U.S. health care system is in crisis. American patients, their families and other caregivers, their employers, their health benefit programs, their health care providers, the communities and even our federal health care budget increasingly are burdened and overwhelmed by the mounting obstacles to caring for our ill, disabled, and aging citizens within our health care system and the extraordinary expense of maintaining and using that system.

As Congress takes up reform again, it is critical that Americans act to protect their own and their families’ health care and control the financial burdens of health care by getting informed, providing clear and consistent direction to Congress and other reformers and taking other actions to empower and care for themselves and their loved ones within our evolving health care system.

©2017 Cynthia Marcotte Stamer. Non-exclusive right to republish licensed to Solutions Law Press, Inc. For information about republication of this or other materials and programs of the author, email the author here.   All rights reserved.

Senate Majority Leader Reid Unveils “Patient Protection and Affordable Care Act

Senate Majority Leader Harry Reid yesterday (November 18, 2009) unveiled the text of his proposed “Patient Protection and Affordable Care Act, H.R. 3590” health care reform bill that he indicated that he and certain other key Senate Democrats now back.

Senate Majority Leader Harry Reid yesterday (November 18, 2009) unveiled the text of his proposed 2,074-page “Patient Protection and Affordable Care Act, H.R. 3590” health care reform bill that he indicated that he and certain other key Senate Democrats now back. 

Based on text of the legislation shared by Senator Reid yesterday available for review here,  the public insurance option provisions in H.R. 3590 would offer states the opportunity to opt out of the program rather than the mandatory public option provided for in the “Affordable Health Care for America Act,  HR. 3962 passed by the House of Representatives on November 7, 2009.  The Congressional Budget Office (CBO) estimates, H.R. 3962 costs at just over $1 trillion.  In comparison, CBO estimates the cost of H.R.3590 at $848 billion. For more details of the Congressional Budget Office estimates the cost of H.R. 3590 as proposed by Senator Reid,  see at here.

Meanwhile, Senate Finance Committee Chairman Max Baucus (D-MT) today (November 19, 2009) introduced his latest health care reform proposal, the America’s Healthy Future Act of 2009 (S.1796).  

Many perceive that substantial negotiation and compromise may be necessary before  Senate Majority Leaders will be able to craft a health care reform bill that can both garner the necessary votes to pass the Senate and have a viable chance of surviving the required negotiation with House leaders necessary to reconcile that legislation with the provisions of HR 3962. As was the case with HR. 3962, members of the Senate are likely to debate and weigh a variety of amendments and refinements to the provisions of S.1796 as it deliberates its enactment.  If you or someone else you know would like to receive updates about health care reform proposals and other related legislative, regulatory, and enforcement developments, please:

  • Register for this resource at the link above;
  • Join the Coalition for Responsible Health Policy group at linkedin.com to share information and input and join in other dialogue with others concerned about health care reform;
  • Share your input by communicating with key members of Congress on committees responsible for this legislation and your elected officials directly and by actively participating in and contributing to other like-minded groups; and
  • Be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here

If you have questions about or need assistance evaluating, commenting on or responding to health care or other legislative or regulatory reforms, or any other employment, compensation, employee benefit, workplace health and safety, corporate ethics and compliance practices, concerns or claims, please contact the author of this article, Curran Tomko Tarski LLP Labor & Employment/Employee Benefits  Practice Chair Cynthia Marcotte Stamer. 

Ms. Stamer has more than 22 years of experience advising and assisting business, government and other clients to evaluate and respond to health care, pension reform, workforce and other proposed or adopted changes in federal or state health care, employee benefit, employment, tax and other federal and state laws.  A member of the leadership council of the American Bar Association Joint Committee on Employee Benefits, Chair of the ABA Real Property, Probate & Trust Section and Employee Benefits & Compensation Group and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group Ms. Stamer is highly regarded legal advisor, policy advocate, author and speaker recognized both nationally and internationally for her more than 20 years of work assisting U.S. public and private employers, health care providers, health insurers, and a broad range of other clients to respond to these and other health care, employee benefit and workforce public policy, regulatory and compliance and risk management concerns within the U.S. as well as internationally.  Her work includes extensive involvement providing input and assistance about health care, workforce, pensions and social security and other reforms domestically and internationally.  In addition to her continuous involvement in U.S. health care, pensions and savings, and workforce policy matters, Ms. Stamer has served as an advisor on these matters internationally.  As part of this work, she served as a lead advisor to the Government of Bolivia on its social security reform as well as has provided input on ethics, medical tourism, workforce and other reforms internationally.

In addition to her extensive work on health and other employee benefit matters, Ms. Stamer also is Board Certified in Labor & Employment Law by the Texas Board of Legal Specialization and has continuously has advised and represented employers and others on labor and employment, compensation, employee benefit and other personnel and staffing matters throughout her career. Ms. Stamer is experienced with assisting employers and others about compliance with federal and state equal employment opportunity, compensation and employee benefit, workplace safety, and other labor and employment, as well as advising and defending employers and others against tax, employment discrimination and other labor and employment, and other related audits, investigations and litigation, charges, audits, claims and investigations by the IRS, Department of Labor and other federal and state regulators. Ms. Stamer is a widely published author and popular speaker on health plan and other human resources, employee benefits and internal controls issues.   Her work has been featured and published by the American Bar Association, BNA, SHRM, World At Work, Employee Benefit News and the American Health Lawyers Association.  Her insights on human resources risk management matters have been quoted in The Wall Street Journal, the Dallas Business Journal, Managed Care Executive, HealthLeaders, Business Insurance, Employee Benefit News and the Dallas Morning News.

If your organization needs assistance with monitoring, assessing, or responding to these or other health care, employee benefit or human resources reforms,  please contact Ms. Stamer via e-mail here, or by calling (214) 270-2402.  For additional information about the experience, services, publications and involvements of Ms. Stamer specifically or to access some of her many publications, see here. For additional information about the experience and services of Ms. Stamer and other members of the Curran Tomko Tarksi LLP team, see here.

Other Information & Resources

We hope that this information is useful to you. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to participate in the distribution of our Solutions Law Press HR & Benefits Update distributions here.  Some other recent updates that may be of interested include the following, which you can access by clicking on the article title:

Proposed Chemical Facility Anti-Terrorism Bill Would Obligate Chemical Facilities To New Background Check, HR & Other Safety & Security Safeguards

IRS Rules For Employer Reporting Of Wages Paid to Nonresident Alien Employees Performing Services In U.S. Change

House Passes Affordable Health Care For America, Health Care Reform Debate Focus Now Moves To The Senate

SHRM Tells Members Say “NO!” To Pelosi-Backed Health Care Reform

IRS Updates Procedures Qualifying Small Employers Can Use To Qualify To Report Employment Taxes Annually Rather Than Quarterly

OSHA Proposes To Change Hazard Communication Standard

IRS Proposes Changes In Actuarial Enrollment Standards For Performance of Actuarial Services Under the Employee Retirement

EEOC Prepares To Broaden “Disability” Definition Under ADA Regulations

IRS Proposes To Update Regulations On Exclusion of Damages Received on Account of Personal Physical Injuries or Physical Sickness To Eliminate Tort Test

OSHA Final Rule Updates OSHA Personal Protective Equipment Standards

DOL Proposes Changes To H-2A Temporary & Seasonal Agricultural Nonimmigrant Worker Certification Procedures & Related Rules

ADAAA Amendment Broader ADA “Disability” Definition Not Retroactive, Employer Action Needed To Manage Post 1/1/2009 Risks

New Study Shares Data On Migrant Health Care Challenges Along The Border

Employer & Other Health Plans & Other HIPAA-Covered Entities & Their Business Associates Must Comply With New HHS Health Information Data Breach Rules By September 23

HHS Reassignment Of HIPAA Enforcement Duties Signals Rising Seriousness of Enforcement Commitment

Speak Up America: Where & How To Read & Share Your Feedback About The Health Care Reform Legislation

For important information concerning this communication click here.   If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject here.

©2009 Cynthia Marcotte Stamer. All rights reserved. 

Senate Finance Committee Chair Baucus Introduces New Version of Health Care Reform, The America’s Healthy Future Act of 2009

Senate Finance Committee Chairman Max Baucus (D-MT) today (November 19, 2009) introduced his latest health care reform proposal, the America’s Healthy Future Act of 2009 (S.1796), the text of which is available for review here. Chairman Baucus’ introduction of S. 1796 follows the November 7, 2009 passage by the U.S. House of Representatives of the massive health care reform proposal sponsored by Representative John Dingell (D-MI) and supported by Speaker Nancy Pelosi, the Affordable Health Care for America Act (HR. 3962). Review highlights and get link to text of bill here!

Senate Finance Committee Chairman Max Baucus (D-MT) today (November 19, 2009) introduced his latest 1504 page health care reform proposal, the America’s Healthy Future Act of 2009 (S.1796), the text of which is available for review here.   Chairman Baucus’ introduction of S. 1796 follows the November 7, 2009 passage by the U.S. House of Representatives of the massive health care reform proposal sponsored by Representative John Dingell (D-MI) and supported by Speaker Nancy Pelosi, the Affordable Health Care for America Act (HR. 3962).   

Totaling 1504 pages in length, S.1796 proposes a lengthy and complex array of reforms to the U.S. health care coverage and delivery system, which would affect virtually each U.S. employer, health care provider, payer, and resident. As with the provisions of HR. 3962 and other versions of health care reform, the reforms outlined in the provisions of S.1796 include complexities and nuances which may not be apparent in partisan or non-partisan discussions or summaries of its goals or purposes. Consequently, individuals or businesses concerned about the proposed reforms are encouraged to begin and base their review and analysis on the actual text of S.1796, a copy of which as introduced is available for review here.   

The continuing emphasis of President Obama and other members of the Democratic Party Leadership in Congress on the passage of health care reform means that Senator Baucus and other Democratic Leaders in Congress are likely to continue to make passage of health care reform a priority.  U.S. businesses and individuals concerned about the proposed reforms should carefully review both the Senate and House bills and act quickly to provide their input on any matters of special interest and concern.

Selected Health Coverage Reform Highlights

Among other things, S.1796, as introduced, would enact sweeping health insurance coverage reforms that would create new obligations for employers, insurers, and individual workers.  In this respect, S.1796, among other things would:

  • Amend the Social Security Act (SSA) to add a new title XXII (Health Insurance Coverage) to ensure that all Americans have access to affordable and essential health benefits coverage.
  • Require all health benefits plans offered to individuals and employers in the individual and small group market to be qualified health benefits plans (QHBPs).
  • Amend the Internal Revenue Code to: (1) allow tax credits related to the purchase of health insurance through the state exchanges; and (2) impose an excise tax on individuals without essential health benefits coverage and on employers who fail to meet health insurance coverage requirements with respect to their full-time employees.
  • Prohibit QHBP from excluding coverage for preexisting conditions, or otherwise limiting or conditioning coverage based on any health status-related factors.
  • Require QHBPs to offer coverage in the individual and small group markets on a guaranteed issue and guaranteed renewal basis.
  • Amend the cafeteria plan rules of Internal Revenue Code § 125 to, among other things, require that in order for a health flexible spending arrangement (HFSA) to qualify as a qualified benefit eligible to be offered under a cafeteria plan, the cafeteria plan must limit the maximum salary reduction contribution per employee per taxable year to $2,500 beginning in 2011.
  • Increase the threshold for the itemized income tax deduction for medical expenses.
  • Require states to: (1) establish rating areas; (2) adopt a specified risk adjustment model; and (3) establish transitional reinsurance programs for individual markets.
  • Require QHBP offerors in the individual and small group markets to consider all enrollees in a plan to be members of a single risk pool.
  • Require the Secretary of Health and Human Services (HHS) to establish: (1) risk corridors for certain plan years; (2) high risk pools for individuals with preexisting conditions; (3) a temporary reinsurance program for retirees covered by employer-based plans; and (4) a program under which a state establishes one or more QHBPs to provide at least an essential benefits package to eligible individuals in lieu of offering coverage through an exchange.
  • Entitle a qualified individual to the choice to enroll or not to enroll in a QHBP offered through an exchange covering the individual’s state as well as QHBPs in the individual market while at the same time requiring that such individuals to be U.S. citizens or lawful residents.
  • Require each state to establish: (1) an exchange designed to facilitate enrollment in QHBPs in the individual market; and (2) a Small Business Health Options Program (SHOP) exchange designed to assist qualified small employers in facilitating the enrollment of their employees in QHBPs in either the individual or the small group market.
  • Direct the Secretary to: (1) establish a system allowing state residents to participate in state health subsidy programs; and (2) study methods exchange QHBPs can employ to encourage health care providers to make increased meaningful use of electronic health records.
  • Dictate the mandated contents of an essential health benefit benefits package, including little or no cost-sharing, no annual or lifetime limits on coverage, and preventive services.
  • Amend the Internal Revenue Code to codify and revise the Health Insurance Portability and Accountability Act of 1996 (HIPAA) wellness program regulations.
  • Amend the Internal Revenue Code to codify and revise the Health Insurance Portability and Accountability Act of 1996 (HIPAA) wellness program regulations.
  • With regard to abortions: (1) declare that the Act does not require health care benefits plans to provide coverage for abortions; prohibit QHBPs from discriminating against any individual health care provider or health care facility because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions; (3) continues application of state and federal laws regarding abortion; (4) prohibit the use of premium credits and cost-sharing subsidies for QHBPs covering abortion services for which federal funding is prohibited; (5) require the plan offeror to determine whether or not the plan provides coverage of abortion services for which federal funding is prohibited or is allowed; and  (6) require the Secretary to assure that at least one QHBP covers abortion services for which federal funding is prohibited or allowed; and at least one QHBP that does not cover abortion services for which federal funding is allowed.

Selected Health Care System, Reimbursement & Other Reform Highlights

S.1796 also would expand and modify existing Medicare, Medicaid, CHIP and other federal health care programs and enact a host of other new rules and requirements affecting health care providers, drug companies and other participants in the U.S. health care system.  The proposed reforms include provisions that would:

  • Require the President to: (1) certify annually in the President’s Budget whether or not the provisions in this Act will increase the budget deficit in the coming fiscal year; and (2) instruct the HHS Secretary and the Secretary of the Treasury to make required reductions in exchange credits and subsidies.
  • Establish a new mandatory eligibility category under SSA title XIX (Medicaid) for all non-elderly, nonpregnant individuals who are otherwise ineligible for Medicaid.
  • Revise Medicaid benefits.
  • Rescind funds available in the Medicaid Improvement Fund for FY2014-2018.
  • Make appropriations for Aging and Disability Resource Center initiatives.
  • Increase the federal medical assistance percentage (FMAP) for states to offer home and community-based services as a long-term care (LTC) alternative to nursing homes.
  • Create a Community First Choice Option.
  • Add a new optional categorically needy eligibility group to Medicaid for individuals: (1) with income that exceeds 133% of the poverty line; and (2) certain other individuals, but only for benefits limited to family planning services and supplies.
  • Direct the Secretary to establish a grants program to support school-based health centers.
  • Remove smoking cessation drugs, barbiturates, and benzodiazepines from Medicaid’s excluded drug list.
  • Revise requirements for Medicaid disproportionate share hospital (DSH) payments.
  • Direct the Secretary to establish a Federal Coordinated Health Care Office within the Centers for Medicare & Medicaid Services (CMMS).
  • Direct the Secretary to establish a Medicaid Quality Measurement Program.
  • Revise requirements for the Medicaid and CHIP Payment and Access Commission (MACPAC) under SSA title XXI, Children’s Health Insurance Program.
  • Set forth special rules relating to American Indians and Alaska Indians.
  • Require the Secretary to establish procedures for sharing data collected under a federal health care program on race, ethnicity, sex, primary language, type of disability, and related measures and data analyses.
  • Amend SSA title V with respect to the Maternal and Child Health (MCH) block grant program.
  • Provide funding for abstinence education.
  • Incorporate reforms originally proposed under the Elder Justice Act of 2009 pursuant to which amendments would be made to the provisions of SSA title XX relating to Block Grants to States for Social Services with respect to elder abuse, neglect, and exploitation and their prevention.
  • Establish within the Office of the Secretary an Elder Justice Coordinating Council.
  • Direct the Secretary to establish a hospital value-based purchasing program under Medicare.
  • Extend the Medicare Physician Quality Reporting Initiative program (PQRI) incentive payments beyond 2010.
  • Modify the Physician Feedback Program.
  • Require the Secretary to develop a plan to implement a Medicare value-based purchasing program for home health agencies and skilled nursing facilities (SNFs).
  • Amend SSA title XVIII (Medicare) to direct the Secretary to establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.
  • Direct the President to convene an Interagency Working Group on Health Care Quality.
  • Amend the General Provisions of SSA title XI to provide for the establishment of a Center for Medicare and Medicaid Innovation within CMMS.
  • Amend SSA title XVIII to direct the Secretary to establish a shared savings program that promotes accountability for a patient population and coordinates items and services under Medicare parts A (Hospital Insurance) and B (Supplementary Medical Insurance).
  • Create a Hospital Readmissions Reduction Program.
  • Direct the Secretary to establish a Community-Based Care Transitions Program.
  • Revise requirements with respect to residents in teaching hospitals.
  • Increase the Medicare physician payment update.
  • Direct the Secretary to establish a Working Group on Access to Emergency Medical Care.
  • Extend the Medicare-Dependent Hospital Program.
  • Amend the Tax Relief and Health Care Act of 2006 with respect to the hospital wage index.
  • Establish a Medicare prescription drug discount program for brand-name drugs for beneficiaries who enroll in Medicare part D (Voluntary Prescription Drug Benefit Program) and have drug spending that falls into the coverage gap.
  • Establish an independent Medicare Commission to reduce the per capita rate of growth in Medicare spending.
  • Amend SSA title XI to add a new part D, Comparative Effectiveness Research, under which would be established a Patient-Centered Outcomes Research Institute.
  • Establish in the Department of Treasury the Patient-Centered Outcomes Research Trust Fund.
  • Establish a nationwide program for national and state background checks on direct patient access employees of long term care facilities and providers.
  • Direct the Secretary to establish new procedures for screening providers of medical or other items or services and suppliers under the Medicare, Medicaid, and CHIP programs.
  • Direct the Secretary to establish a self-referral disclosure protocol to enable health care service providers and suppliers to disclose violations.
  • Requires the Secretary to expand the number of areas included in Round Two of the durable medical equipment (DME) competitive bidding program.
  • Extend the period for collection of overpayments due to fraud.
  • Amend the Internal Revenue Code with respect to: (1) an excise tax on the excess benefit of high cost employer-sponsored health coverage; (2) distributions from health savings accounts for drugs and insulin that are prescribed drugs and insulin only; (3) a limitation on salary reduction contributions by employers to a health flexible spending arrangement; (4) expanded information reporting requirements; (5) additional qualifying requirements for charitable hospital organizations; and (6) a qualifying therapeutic discovery project tax credit.
  • Impose annual fees on: (1) manufacturers and importers of branded prescription pharmaceuticals or of medical devices; and (2) health insurance providers.
  • Prescribe a special rule to limit excessive remuneration by certain health insurance providers.
  • Exclude from an individual’s gross income the value of any qualified Indian health care benefit.

The continuing emphasis of President Obama and other members of the Democratic Party Leadership in Congress on the passage of health care reform means that Senator Baucus and other Democratic Leaders in Congress are likely to continue to make passage of health care reform a priority.  U.S. businesses and individuals concerned about the proposed reforms should carefully review both the Senate and House bills and act quickly to provide their input on any matters of special interest and concern. 

Assistance Monitoring & Responding To Health Care Reform Proposals

As was the case with HR. 3962, members of the Senate are likely to debate and weigh a variety of amendments and refinements to the provisions of S.1796 as it deliberates its enactment.  If you or someone else you know would like to receive updates about health care reform proposals and other related legislative, regulatory, and enforcement developments, please:

  • Register for this resource at the link above;
  • Join the Coalition for Responsible Health Policy group at linkedin.com to share information and input and join in other dialogue with others concerned about health care reform;
  • Share your input by communicating with key members of Congress on committees responsible for this legislation and your elected officials directly and by actively participating in and contributing to other like-minded groups; and
  • Be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here

You can register to receive future updates on legislative and regulatory health care reform proposals and other related information by registering for this resource or access other publications by Ms. Stamer and access other helpful resources here.

Long-time health policy advocate and advisor Cynthia Marcotte Stamer has more than 22 years of experience advising and assisting clients to evaluate and respond to health care reform proposals and other proposed or adopted changes in federal or state health care, employee benefit, employment, tax and other federal and state laws.  Former Chair of the American Bar Association’s Managed Care & Insurance Section, Ms. Stamer is highly regarded legal advisor, policy advocate, author and speaker recognized both nationally and internationally for her more than 20 years of work assisting U.S. public and private employers, health care providers, health insurers, and a broad range of other clients to respond to these and other health care, employee benefit and workforce public policy, regulatory and compliance and risk management concerns within the U.S. as well as internationally.  Her work includes extensive involvement providing input and assistance about health care, workforce, pensions and social security and other reforms domestically and internationally.  In addition to her continuous involvement in U.S. health care, pensions and savings, and workforce policy matters, Ms. Stamer has served as an advisor on these matters internationally.  As part of this work, she served as a lead advisor to the Government of Bolivia on its social security reform as well as has provided input on ethics, medical tourism, workforce and other reforms internationally.

Ms. Stamer is a widely published author and popular speaker on health plan and other human resources, employee benefits and internal controls issues.   Her work has been featured and published by the American Bar Association, BNA, SHRM, World At Work, Employee Benefit News and the American Health Lawyers Association.  Her insights on human resources risk management matters have been quoted in The Wall Street Journal, the Dallas Business Journal, Managed Care Executive, HealthLeaders, Business Insurance, Employee Benefit News and the Dallas Morning News.

Ms. Stamer also serves in a number of professional leadership roles including the leadership council of the American Bar Association Joint Committee on Employee Benefits, Chair of the ABA Real Property, Probate & Trust Section and Employee Benefits & Compensation Group and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group.

If your organization needs assistance with monitoring, assessing, or responding to these or other health care, employee benefit or human resources reforms,  please contact Ms. Stamer via e-mail here, or by calling (214) 270-2402.  For additional information about the experience, services, publications and involvements of Ms. Stamer specifically or to access some of her many publications, see here

Additional Resources & Information

We hope that this information is useful to you. For additional information about the experience, services, publications and involvements of Ms. Stamer specifically or to access some of her many publications, see here.  If you would prefer not to receive electronic distributions of these updated in the future, send your request with the word “unsubscribe” in the Subject to here.

©2009 Cynthia Marcotte Stamer. All rights reserved.

House Leaders Plan To Work Out Differences In 3 Versions of Health Care Reform Legislation Passed By Key Committees During Recess

Democratic Leaders in the House of Representatives plan to hammer out differences three versions of the America’s Affordable Health Choices Act (H.R. 3200) as separately passed by three key House Committees in July before House members return from their August recess in hopes of bringing the agreed to version of H.R. 3200 to the full house in September. Learn where to review different versions passed by these Committees here.

Democratic Leaders in the House of Representatives plan to hammer out differences three versions of the America’s Affordable Health Choices Act (H.R. 3200) as separately passed by three key House Committees in July before House members return from their August recess in hopes of bringing the agreed to version of H.R. 3200 to the full house in September.  

After negotiating a last minute pre-August recess deal with certain Blue Dog Democrat Committee members, the House Energy and Commerce Committee on July 31, 2009 passed its version of H.R. 3200, the America’s Affordable Health Choices Act (H.R. 3200). The version of H.R. 3200 passed by the House Energy and Commerce Committee incorporates a series of amendments to the language of H.R. 3200 as originally introduced.  For instance, this version of H.R. 3200 provides incentives for states to adopt certain tort reforms, provides for a public plan option that would reimburse physicians based on negotiated rates rather Medicare rates, and would allow states to offer both state-based heath insurance exchanges and health insurance co-ops. To review H.R. 3200 as amended by the House Energy and Commerce Committee, see here.

The approval by the Energy and Commerce Committee of its version of H.R. 3200 follows the July 17, 2009 approval by the House Ways and Means Committee and Education and Labor Committee of their own versions of H.R. 3200.  For details on the version of H.R. 3200 approved by the House Ways and Means Committee, see here.  For details on the version of H.R. 3200 approved by the House Education and Labor Committee, see here

Leading House Democrats have announced their intention to work to resolve differences between these three versions of H.R. 3200 as passed by these Committees during August recess in hopes of  bringing the agreed to version of H.R. 3200 to a vote  of the full House of Representatives in September.

Meanwhile, House members from both parties also generally are using the August recess as an opportunity to reconnect with local constituents on health care reform and other core issues.

For More Information 

 The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns.  You can get more information about her health industry experience here.  

We hope that this information is useful to you.  If you need assistance monitoring, evaluating or responding to these or other proposed health care or other regulatory reforms or with other health care compliance, risk management, transaction or operation concerns, please contact the author of this update, Curran Tomko Tarski LLP Health Practice Group Chair, Cynthia Marcotte Stamer, at (214) 270-2402, cstamer@cttlegal.com or your other favorite Curran Tomko Tarski LLP Partner.

We also encourage you and others to join the discussion about these and other health care reform proposals and concerns by joining the Coalition for Responsible Health Care Reform Group on Linkedin, registering to receive these updates here.

The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns.  You can get more information about her health industry experience here.  If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information to cstamer@cttlegal.com.

Where To Read Health Care Reform Bills Backed By House, Senate Democratic Leaders

Find links to text of H.R. 3200: America’s Affordable Health Choices Act of 2009 as introduced on July 14, 2009 and S. __, the Affordable Health Choices Act approved by the Senate Committee on Health, Education, Labor and Pensions

As the health care reform policy debate continues, Americans increasingly are asking where to read the text of the health care reform legislation that members of Congress are debating.  While numerous alternatives presently are pending before Congress, much of recent discussion and debate has focused around one of the following bills:

  • H.R. 3200: America’s Affordable Health Choices Act of 2009 introduced in the House by Rep Dingell, John D. on July 14, 2009, the text of which as originally introduced may be reviewed  here;
  • S. __, the Affordable Health Choices Act approved by the Senate Committee on Health, Education, Labor and Pensions, the text of which as approved may be reviewed here.

We also encourage you and others to join the discussion about these and other health care reform proposals and concerns by joining the Coalition for Responsible Health Care Reform Group on Linkedin, registering to receive these updates here The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns.  You can get more information about her health industry experience here.  

Interested persons can find information about Co-Sponsors, key legislative actions and other information about this and other health care reform legislation here

The Coaltion for Patient Empowerment (COPE) will host a Dallas/Fort Worth town hall meeting featuring Congressman Pete Sessions (R-TX) and Congresswoman Eddie Bernice Johnson (invited) on August 17, 2009 at Southern Methodist University in Dallas, Texas beginning at 8:30 a.m.  For more information about the town hall meeting, how your organization can partner in co-hosting this town hall meeting or in organizing other town hall meetings or activities, or how you or your organization can participate in these and other COPE activities, e-mail the COPE Event Chair, Cynthia Stamer, at cstamer@solutionslawyer.net.

 

The Real Opportunities To Improve Health Care- A 10 Step Program

To really make a difference, Congress and Americans need to stop pretending that they can waive a magic wand and “fix” health care. There are no easy fixes. There are just a series of tough realities and steps that all Americans have to embrace. The following are 10 key realities:

The ongoing health care reform debate in Washington requires that all Americans including those in Congress to seize the opportunity to show true leadership on health care reform by dong their part to making health care work.

To really make a difference, Congress and Americans need to stop pretending that they can waive a magic wand and “fix” health care.  There are no easy fixes.  There are just a series of tough realities and steps that all Americans have to embrace to improve health care in the United States.   If you agree with the health care truths discussed in this Article, let all members of Congress know your feelings and join the Coalition For Responsible Health Care Reform group on linkedin to discuss and plan specific steps that you can take to improve health care for your family and others in your community.

10 Health Care Truths

The following are 10 key realities: 

  1. Being old or being sick (or having a loved one who is) stinks. Not everyone was born with a BMW for a body and even some BMW’s are lemons.  Wellness can delay this reality for some people but not everyone.  I don’t live an unhealthy life.  I don’t smoke, don’t do drugs, exercise, etc., yet I’ve had cancer twice.  A good friend who lives a totally healthy life is awaiting a heart transplant at 47.   Even for a car, there isn’t always a clear “evidence based” answer to the questions what’s wrong, how to fix it, when the expense is worth it and how do I find the money and other resources? Sometimes you just have to just keep pouring in more oil and let it leak. The government can’t change this anymore than anyone else. 
  2. Money only can do so much to fix item 1 and there isn’t enough money to fix what can be fixed for everyone (assuming there is a fix).   We can put more money into the system if Americans support taking money from somewhere else to provide more money for health care.  Individual families currently make these choices by deciding whether to buy and how much coverage they can afford without giving up other things that their family views as more necessary than health care coverage.  Congressional proposals would take this choice away from American families by dictating both how much and the price of coverage a family must buy as well as how much that American family also must pay to buy health coverage for other Americans. 
  3. The aging population means that the gap between 1 and 2 will continue to grow unless we adopt a rationing plan that decides to let people die by denying care. Many old and sick people are extraordinary functional, valuable and important to someone.   If the government chooses to replace private insurers in running the health care system, grieving families of ill and individuals will be mad at the government when their family members die or suffer because they can’t access or afford health care that the doctors say would help.
  4. Just because the most health care dollars are spent in the last months of life doesn’t mean that these dollars are necessarily wasted. Likewise, pouring dollars into “prevention” doesn’t mean that a large number of people won’t still get older or sick.  People that live healthy lives get sick, have accidents, and get old.  The body wears out.  The ability and practice of the US health care system in saving hands of minimum wage workers, providing diagnosis that extends the range of treatment options and gives people with terminal illness 6 months to 5 years of life, providing treatments that minimize disability and maximize functionality are all good things. The U.S. willingness to invest in our aging and disabled is part of the reason our disabled and aging people tend to be more productive than in other countries less willing to invest in these treatments.  The question should be what quality of life and value was realized for the dollars spent.   
  5. The most overlooked opportunities for quality and cost improvements rest with the people in health care. Studies show that physicians and the RNs working with them agree in less than 70 percent of the times about the care ordered and how to administer it. Communication elsewhere among health care providers further erodes cost effectiveness and quality. Government regulation and the tension that results from regulation and practices that break up health care teams makes this worse contributes to this problem.   Congress’ over regulation of health care and efforts to manipulate health care by manipulation of the Medicare rules already has done tremendous damage by forcing providers to run rabbit trails to try to deliver care.  More Federal involvement will just make this worse. 
  6. Americans want to be good health care consumers.  They just need training and tools to do it better.  We need a national health care consumer education campaign that teaches Americans to better participate in our health care system.  Patients and their families will better manage their own health care when they have better health care information and health care skills training.  Skills training can reduce waste and suffering that happens when patients don’t comply with health care advice and make misinformed decisions.  When families and patients get good information that indicates that the $20,000 spent for a procedure will only cause a lot of suffering and expense to extend a life already suffering for another 48 hours, they usually chose quality of life over length of life.  Families that learn that the less expensive drug works as well as the more expensive one usually will opt for the less expensive one to realize the smaller co-pay. Patients and their families need to be taught to be good and responsible health care patients and to help others in their families and the community to do the same.  The government, health care providers, insurers and community organizations can help by providing education and resources to share this education.  make this easier. Let’s give American’s a health care loaf and turn them loose.  
  7. Americans dont want someone else to manage their health care;  they want more power to manage it themselves.  Current proposals that would give government more control over health care is the last things Americans want.  Instead of taking more control away from individual Americans, Congress should work to empower patients by creating real jobs, funding public, charity, and private indigent care health clinics, hospitals and other venues that service the poor, reducing taxes and other actions that will free uo dollars for businesses and individuals to invest more in wellness and health care coverage.
  8. Change creates additional costs and disruptions that will drive up costs and reduce quality.  The constant changing of the system and the resulting confusion that patients, payers and providers experience accounts for much of the lost quality, high cost and dissatisfaction in the system. 
  9. You can’t change patient conduct by fiat.  Overcoming obesity and other lifestyle diseases is tough even when micromanaged.  Lack of money isn’t the only reason people don’t have health insurance coverage or obtain care with the rationality of a mad scientist accountant. 
  10. Government is the last entity that should have the right to determine – directly or through a politically appointed board – the value of a life and the quality of life members of my family and yours are allowed to access. Government action is always political – even when made by private politically appointed boards. Letting the government “manage” care instead of insurers just lets a bigger, more insulated fox in the hen house. This fox is bigger, more powerful, less accessible, harder to talk to, impossible to be heard by and doesn’t give a darn individually about you, me, or your family.  Anyone who has relied on home health benefits from Medicare or benefits from the VA knows you can’t trust Congress to deliver on its promises.  Whatever the government allocates for health care funding today, informed American voters know that they can’t count on government providing the funds to keep its promises.  These American’s and the millions who know they know this reality:   When the government says “trust me,” run!

What Congress Should Do  To Improve Health Care

Let’s stop pretending there is an easy fix and get onto the business of working item by item on what we can do with these and the hundreds of other little things that together actually will make a massive difference in the real life of patients and their families AND produce meaningful improvements in heath care cost, quality and access.

  • Tell every member of Congress to say “no” to proposals to spend $1 trillion dollars to give the federal government the ability to “manage” health care
  • Tell Congress you want to manage and coordinate your own health care, not delegate that to government to handle
  • Tell Congress to adopt legislation that would make it easier for churches and other community and business associations to pool together and offer coverage along side the existing employer-provided systems
  • Tell Congress to support and fund public and private efforts to develop and communicate tools and education to empower patients to better manage their own health, wellness and their family’s health care needs
  • Tell Congress not to tax employer provided health care coverage and to provide tax-credits to businesses and individuals to make maintaining private health care coverage more affordable
  • Get involved in your family and community in building your own, your family’s and your community’s health care plan.  Build and use your health care consumer and management skills to manage your family’s health and health care.

House Democrats Introduce “America’s Affordable Health Choices Act of 2009″

House Democrats introduced their proposal for health care reform this afternoon (July 14, 2009), the “America’s Affordable Health Choices Act of 2009 (the “House Bill”). Democrat leaders have announced plans to fast track the House Bill to a vote by the end of July. See a high level summary of certain core provisions in the House Bill, as described by House Democrats in connection with their release of the proposal.

House Democrats introduced their proposal for health care reform this afternoon (July 14, 2009), the “America’s Affordable Health Choices Act of 2009 (the “House Bill”).  Introduced under the sponsorship of three key House committees -Energy and Commerce, Ways and Means, and Education and Labor — the 1018 page House Bill details the sweeping and comprehensive health care reforms that Democrat Leaders in the House are touting.  A copy of the House Bill as introduced may be reviewed here.

The House Bill proposes sweeping reforms built around the establishment of a public plan option while technically continuing to permit private plans to operate but in a federally regulated form allowing for little meaningful plan design control to private payers, health care providers or the individuals choosing among the plan options.   The Congressional Budget Office estimates that the coverage side of the bill will cost $1 trillion and cover 97 percent of the legal population within 10 years.

The following is a brief overview of certain key provisions of the House Bill drawn mostly from a series of high level summaries released by House Democrats along with the House Bill.  Long on politically comforting phrasing and short on details, you can read these summaries here.

Public Plan Option.  The House Bill proposes the establishment of a public health insurance option that would compete with allowable private plans, both of which would be subject to sweeping federal controls.  Democrat House co-sponsors represent the House Bill:

  • Provides a public health insurance option that would compete with private insurers within the Health Insurance Exchange.
  • The public health insurance option would be made available in the new Health Insurance Exchange (Exchange) along with private health insurance plans that comply with the design dictates established in the House Bill.
  • The public health insurance option and private plan options meet the same benefit requirements and comply with the same insurance market reforms
  • The public option’s premiums would be established for the local market areas designated by the Exchange.
  • Individuals with affordability credits could choose among the private carriers and the public option.
  • Require that the public health plan and private health plan options and private options each must be financially self-sustaining
  • Promote primary care, encourage coordinated care and shared accountability, and improve quality.
  • Institute new payment structures and incentives to promote these critical reforms.
  • Specify health care provider participation in the plans will be voluntary; Medicare providers are presumed to be participating unless they opt out.
  • Provides for provider reimbursements for services from the plans initially will be established using “rates similar to those used in Medicare with greater flexibility to vary payments.
  • Speaker of the House Nancy Pelosi has announced plans to proceed immediately on mark up on the House Bill with the intention to of scheduling a vote on the House Bill by the end of July. Assuming that House leaders adhere to this schedule, the planned timetable leaves little opportunity for critical evaluation and input by members of Congress or the public who may have questions or concerns about the proposed legislation. Prompt and coordinated action is required for individuals with concerns about any of the proposed reforms.

Federal Mandates Health Plan Benefits.  In order to achieve affordable, quality health care for all, the House Bill would impose federal standards regulating the benefits that the public health plan and private health plans would be required and permitted to offer.  Under these provisions, the House Bill would:

  • Establish a standardized benefit package that covers essential health services.
  • Vest the power in the Secretary of Health & Human Services to decide the coverage that would be included in this mandated standardize benefit package.
  • Eliminate cost-sharing for preventive care (including well baby and well child care)
  • Impose caps annual out-of-pocket spending for individuals and families.
  • Create a new independent Benefits Advisory to recommend to the Secretary and update the core package of benefits.
  • Provide for the public health plan option to offer four tiers of benefit packages from which consumers can choose to best meet their health care needs. Each allowable plan would be required to provide the dictated core benefits.
    • The Basic Plan would include the federally mandated core set of covered benefits and cost sharing protections;
    • The Enhanced Plan would include the federally mandated core set of covered benefits with more generous cost sharing protections than the Basic plan;
    • The Premium Plan would include the federally mandated core set of covered benefits with more generous cost sharing protections than the Enhanced plan; and
    • The Premium Plus Plan would include the federally mandated core set of covered benefits, the more generous cost sharing protections of the Premium plan, and additional covered benefits (e.g., oral health coverage for adults, gym membership, etc.) that will vary per plan. In this category, insurers must disclose the separate cost of the additional benefits so consumers know what they’re paying for and can choose among plans accordingly.

The House Bill empowers the Secretary of Health & Human Services to decide the federally dictated, required core set of benefits provides coverage with input from a newly created Benefits Advisory Commission.  These core benefits are intended to include inpatient hospital services, outpatient hospital services, physician services, equipment and supplies incident to physician services, preventive services, maternity services, prescription drugs, rehabilitative and habilitative services, well baby and well child visits and oral health, vision, and hearing services for children and mental health and substance abuse services.  However, the particular, terms and scope of these benefits is left to HHS to define.

Health Insurance Exchange.  The House Bill also calls for the establishment of a “Health Insurance Exchange” meeting federal mandates through which low income individuals initially, and certain small businesses would be offered the option to purchase health care coverage through federally mandated purchasing groups.  In the first year, the House Bill provides for the Health Insurance Exchange to accept those without health insurance, those who are buying health insurance on their own, and small businesses with fewer than 10 people. In the second year, the Health Insurance Exchange could accept small businesses with fewer than 20 people. After that, “larger employers as permitted by the Commissioner.” In other words, expansion is discretionary, not mandated.

Affordability & Subsidies.  The House Bill provides sliding-scale affordability credits for individuals and families with incomes above the Medicaid thresholds but below 400% of poverty and imposes a cap on total out-of-pocket spending for individuals and families covered under the plans regardless of income.  In addition, the House Bill would broaden Medicaid coverage to include individuals and families with incomes below 133% of poverty.

Effective 2013, sliding scale affordability credits would be provided provided to individuals and families between 133% to 400% of poverty. That means the credits phase out completely for an individual with $43,320 in income and a family of four with $88,200 in income (2009).

The sliding scale credits limit individual family spending on premiums for the essential benefit package to no more than 1.5% of income for those with the lowest income and phasing up to no more than 11% of income for those at 400% of poverty.

The affordability credits also subsidize cost sharing on a sliding scale basis, phasing out at 400% of poverty, ensuring that covered benefits are accessible.

The Health Insurance Exchange would administer the affordability credits in relationship with other federal and state entities, such as local Social Security offices and Medicaid agencies.

The essential benefit package, and all other benefit options, limit exposure to catastrophic costs with a cap on total out of pocket spending for covered benefits. Special provisions would apply to Medicaid. 

Effective 2013, individuals with family income at or below 133% of poverty ($14,400 for an individual in 2009) are eligible for Medicaid. State Medicaid programs would continue to cover those individuals with incomes above 133% of poverty, using the eligibility rules states now have in place.

Paying The Tab.  House Democrats propose to finance approximately half of the estimated $1 trillion bill for their proposed reforms through projected $500 billion or so in savings from Medicare and Medicaid achieved by a variety of reimbursement and benefit cutbacks and other reforms. The rest of the financing would come from a combination of revenue expections from employer and individual mandates (an estimated $200 billion over 10 years) and a surtax on the richest 1.5 percent of Americans. The surtax is 1 percent on income between $350,000 and $500,000; 1.5 percent on income between $500,000 and $1,000,000; and 5.4 percent in income above $1,000,000. The House Bill permits the amount of this surtax to vary if the bill is less or more expensive than initially anticipated.

The author of this article, Curran Tomko and Tarski LLP Health Care Practice Chair Cynthia Marcotte Stamer has extensive experience advising and assisting health industry clients and others about a diverse range of health care policy, regulatory, compliance, risk management and operational concerns.  You can get more information about her health industry experience here.  

If you need assistance evaluating or formulating comments on the proposed reforms contained in the House Bill or on other health industry matters please contact Cynthia Marcotte Stamer, CTT Health Care Practice Group Chair, at cstamer@cttlegal.com, 214.270.2402 or your other favorite Curran Tomko Tarski LLP attorney. 

Other Helpful Resources & Other Information

We hope that this information is useful to you.   If you found these updates of interest, you also be interested in one or more of the following other recent articles published on our electronic Solutions Law Press Health Care Update publication available here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please register to receive this Solutions Law Press Health Care Update here and be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. You can access other recent updates and other informative publications and resources provided by Curran Tomko Tarski LLP attorneys and get information about its attorneys’ experience, briefings, speeches and other credentials here.

For important information concerning this communication click here.  If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject to support@SolutionsLawyer.net.

©2009 Cynthia Marcotte Stamer.  All rights reserved.