Perlukah Anda Merubah Karir ?

Rata-rata setiap orang pernah mengalami perubahan karir didalam kehidupannya. Umumnya tiga sampai lima kali. Salah satu alasannya karena orang sering tidak menyadari dengan pilihan yang diambil. Bukan suatu jaminan bila keputusan yang telah diberitahukan mengenai karir Anda, merupakan cara terbaik untuk membantu memastikan bahwa karir pilihan Anda adalah yang paling tepat bagi Anda. Bahkan walaupun anda mengikuti seluruh langkah yang telah disarankan dan memilih karir yang tepat, tidaklah selalu merupakan pilhan terbaik bagi Anda untuk selamanya.

Berikut ini berapa alasan untuk mempertimbangkan meninggalkan pekerjaan yang sedang Anda geluti saat ini untuk karir yang baru.

Anda harus mempertimbangkan perubahan karir bila...

1. Status

Mungkin pada saat anda memulai karir , anda masih lajang sementara saat ini anda telah berkelarga.

2. Jadwal padat

Jadwal yang luar biasa padat atau frekuensi perjalanan bisnis yang tinggi yang memang merupakan bagian dari pekerjaan Anda mungkin sudah tidak sesuai lagi dengan gaya hidup Anda yang baru. Anda harus mencari pekerjaan yang "sesuai bagi keluarga"

3Tidak berkembang

Pekerjaan Anda membuat anda tidak berkembang bahkn lebih buruk, tidak seperti yang dijanjikan saat anda baru memulai pekerjaan anda. Karena perubaahan keadaan teknolgi ,ekonomi atau industri di tempat anda bekerja, kesempatan berkembang tidak lagi menjanjikan. Anda harus mencari pekerjaan yang dapat membuat Anda berkembang dan maju.

4.Hilang semangat

Anda sudah tidak memiliki semangat kerja lagi. Dulu, pada saat Anda baru memulai pekerjaan Anda, Anda bersemangat setiap kali berangkat kerja. Perasaan itu sudah tidak ada lagi . Tidak ada sesuatu yang dapat memotivasi anda. Mungkin sudah saatnya bagi Anda untuk mendapatkan pekerjaan yang dapat membuat Anda bersemangat dan termotivasi.

Baiklah rekan netter kiranya hanya ini saja dulu yang dapat saya posting, semoga ada manfaatnya.

(sumber:tabloid nova)

salam sukses selalu,

Husein Pratama

Fatwa on the Fat Wallets; the Dismantling of the Middle Class in America

How the latest proposed tax cuts lead to the dismantling of the middle class in America
President Obama’s latest capitulation to the greed of the Republicans is unparalled in the blatant disregard for the middle class of the United States. In the event you are just coming out of a coma let me enlighten you as to the facts on the Obama Tax Cut Proposal.
Social Security is being Dismantled
The financing mechanism for social security has been cut by 30%; further eroding the ability of this program to provide the funds for those who are retired, disabled, as well as for widows and children. This is not some abstract idea to me, as my son lost his father when he was an infant and it has been a long 14 years of scratching by. In order to pay for the current social security benefits the fund has to borrow money, to the tune of 112 million. The reduction in Social Security funding will mean our children will have to pay higher taxes in the future to make up for the funding shortfall, to say nothing of the fact I have paid into it since I was fourteen years old.
Impact on the National Debt
The United States overspending is financed by other countries, including China, who have now decided that the US debt is not such a good investment and they have raised the interest rate the US must pay (which is akin to a drop in the bond rating of the nation). This country is spending 39% of the entire 2010 annual budget on war and half of that is on a discretionary defense budget; since I no longer have a discretionary budget, I suggest we get rid of that expense and balance the budget like the rest of us.
Impact on the Average American
The impotent rational for the give-a-way to the rich was the extension of unemployment benefits to the 15 million people who are out of work, of which I am one. Why does there have to be a rational when the country is in a depression and job cuts are at every level both private sector and in all levels of government? Once again government is out of touch with the daily lives of its citizens.
According to the latest figures from the World Bank the average income in this country is $47,240 and the tax cuts provide less of proportional benefit to the average American, with $1,000 for those earning $50,000 and $2,000 for those earning $100,000. People who earn the former need the money more.
The entire spend for Medicare and Medicaid health care programs is only 23% of the budget and with current Social Security spending that adds another 20%, for a grand total of 43%. Yes, that is right folks; your government spends nearly as much on war as on all of the benefits, which you have paid for, for everyone else in the country. At least Obama has included health care in the benefit equation, but he capitulated on that too, by letting the insurance lobby create an expensive mess instead of more affordable national health care.
The top 3% don’t need the tax breaks and boo hoo on their estate taxes; they set up trusts, and use insurance to pay that tab anyway. And whatever happened to the adage you can’t take it with you?
Conclusion
It is about time the elected officials in this country started having more respect for the poor working stiffs, who are not getting ahead, instead of catering to the rich, who are obviously born under a different star. So Mr. Obama as you continue to spend 40% of the budget on a war that we never should have entered and dismantle my Social Security benefits, I look forward to opening that can of Friskies for dinner. The dismantling of the middle-class will bring a revolution to this country, for which I am prepared to serve. Ending on a positive note I salute Senator Bernard Sanders of Vermont for his nine and a half hour filibuster decrying the injustice of this tax proposal.

This article was written by Roberta E. Winter, MHA, MPA an independent health policy analyst and may be reprinted with her permission.

State by State Analysis of Patient Rights under 2010 Reforms

State Reactions to 2010 Health Care Reforms
A virtual firestorm has ensued with state reactions to some of the federal government mandates under the health care reforms of 2010, from the Patient Protection and Affordable Care Act, the Public Health Services Act, and the Affordable Health Care Act for America. This article reviews two of these bones of contention, including the consumer protection aspects, which impact the Office of Insurance Commissioners and the reproductive rights provisions.
Consumer Protections under Federal Mandates
The federal government has awarded thirty million dollars in grants to the states to shore up their consumer protection services for health insurance policy holders. Since the insurance commissioners of each state are already charged with this duty, are staffed for it, and are funded by a tax on the insurance premiums for each insurer, I struggle with the necessity of this award. The insurance commissioner’s office for each state are very well funded and provide general revenue to each state well beyond their budget requirements. If those states aren’t able to staff appropriately for consumer protections, they should take this up with their state legislatures.
Upon reviewing the mandated consumer protections, they appear to reinforce existing protections in many states, but perhaps the standardization of the process is a good thing overall. Here are the new rules for an insured’s right to appeal a health insurer’s claim decision:
•Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage
•Gives consumers detailed information about the grounds for the denial of claims or coverage
•Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process
•Ensures a full and fair review of the denial
•Provides consumers with an expedited appeals process in urgent cases
These provisions are already spelled out in the Summary Plan Description which employers are required to distribute to medical plan participants as a federal reporting requirement under ERISA health and welfare plans. The new provisions codify what 44 states already have in operation for the outside appeal process. Still, the thirty million dollars to encourage compliance seems like overkill for the six states who are not already meeting these recommended standards, which were created by the National Association of Insurance Commissioners. Basically the new rules specify that the patient has a right to an independent review of a rejected claim. According to the Kaiser Foundation’s report on external reviews of insurance claims, the insured won 44% of the time on appeal. Certainly this is enough of an incentive for many patients to pursue a claim review, but one has to wonder, if it is a life saving treatment, the appeals process could still exhaust the patient’s treatment window for optimal efficacy.

Reproductive Rights under Federal Health Care Reforms
I reviewed legislation for all fifty states as of June 2010 and 86% of them had bills that were introduced to modify their compliance with the federal insurance exchanges and other mandates, to be rolled out in 2014. Basically here is what the fuss is about; the federal standards state that Medicaid and the insurance exchange plans will cover reproductive procedures. Of course this includes abortion and birth control. Since the Hyde Amendment restricts any federal money from paying for abortion, this means the insurance exchanges and Medicaid plans could include abortion coverage but the states or private employers would pay for it. This has raised the hackles of a lot of people, who do not want to be told what to do when they are going to pay the tab. According to a 2003 survey on contraceptive care provided by insurance programs, 87% of private employers offered coverage for abortion services, which covered approximately 46% of the U.S. population. Since the majority of private employer medical plans already cover abortion and birth control procedures for their female workers, this standard is not new. What is new is the government’s attempt to offer the same reproductive rights to low income women through Medicaid and the subsidies for eligible employers. Many of the states are objecting to the federal requirement that they must offer poor women the opportunity to receive birth control treatment. Why don’t you just keep them barefoot and pregnant? Here are my winners and losers on the reproductive rights bills:
Most female friendly regarding reproductive autonomy
Current Laws
Colorado Law 1021 requires insurers to cover contraceptives if they provide maternity coverage. Wisconsin SA458 improves sex education for youth.
Under Consideration
Illinois- Senate Bill 2482 requires insurance companies who provide prescription drug coverage to include coverage for contraceptives. House Bill 6205 codifies the right to abortion even if Roe-v-Wade is overturned. Bill 6205 also assures the right of Medicaid women to receive contraceptives and abortion as needed. House Bill 6842 blocks some access to reproductive health care under federal health reform stipulations.
Let’s give a shout out to South Dakota for proposing insurance companies cover contraceptives, but also for expanding Medicaid for pregnancy related services. Other states who seek to expand Medicaid for low income women are Alaska and Illinois.
The following states have bills stipulating improvements in sex education, emergency contraceptives upon request (morning after pill), and insurance reimbursement for contraceptives: Pennsylvania, New York, Missouri, Minnesota, California, and Hawaii.
Most paternalistic states regarding female reproductive autonomy
Current Law
Providers Can Decline to Provide Contraceptive Services
The following states have enacted laws which allow health care providers (pharmacists or clinicians) to decline to provide birth control services: Idaho S1353 enacted 3/29/2010 and Oklahoma S1891 signed 4/2/2010.
No Abortions under Private Insurance Plans Either
Under current law, the following states do not allow private insurance funding for abortion services; Kentucky, Missouri, Oklahoma, Idaho, and North Dakota. If you are unfortunate enough to live in North Dakota, now is a good time to consider moving over to the healthier and wealthier Minnesota neighbor, though I must confess I am a former Minnesotan.
No Abortions in Health Insurance Exchanges
States which have enacted laws that restrict abortion and other contraceptive services under state health insurance exchanges include Arizona and Mississippi.
Arizona- S1305 enacted 4/24/2010, prohibits insurance companies participating in the insurance exchanges from offering abortion and S1001 signed 4/1/2010, blocks portions of the federal health care reforms. If that isn’t charming enough, S1305 also prohibits insurance companies who cover state employees from offering abortion coverage.
States Seeking to Limit Birth Control specifically for Low Income Women
Virginia H30 passed 5/17/2010 limiting access to abortion for Medicaid eligible women and
Colorado L1311 prohibits the payment of abortion for Medicaid participants.
Pending Bills Restricting Reproductive Rights
North Carolina currently has a law that allows insurance companies to refuse contraceptive coverage, N.C. 1068 and also restricts access to contraceptives in school health services (let's keep those teen pregnancies coming). The coupe de tat’ Bill 890 makes an unborn child a crime victim separate and apart from the mother, legalizing the fetus status as an individual. North Carolina also introduced a bill on 3/31/2010 requiring all pregnant women to get an ultrasound, regardless of efficacy, to submit to a state lecture on fetal development, and to wait 24 hours before termination. Also a bill was introduced on 4/13/09 to prohibit state employees and teachers from having an abortion paid for by state medical plans. I wonder if the school boards can still fire teachers who become pregnant out of wedlock as well. Double winner here, ladies, cross your legs in NC. Bill 1157 would restrict funding for low income women on Medicaid, by not covering birth control services. A bill introduced on 6/17/2010 would block federal health care standards for women. Finally, Bill 431 would require parental consent in writing before getting an abortion. Let’s see, your parents may have a different religion, different sexual orientation, and you may not even be living with them, but you need their permission? How does this work for foster kids and run-a-ways?
Additional States that seek to limit access to sex education, contraceptives, fair access to birth control for low income women (Medicaid), and to criminalize abortion are:
Alabama, Louisiana, Virginia, Colorado, Nevada, New Mexico.
Does this really matter when the 1977 Hyde Amendment has continually been ratified and every federal budget limits payment for abortion procedures except in the case of rape, incest, or a life threatening situation? The tan-your-Hyde amendment has also been broadened to include no federal reimbursement for abortion for federal employees, women in the military, or for Indian Health Services. The latter is a real confounder since American Indian Tribes are considered sovereign nations, yet are conscripted to obtain health care from the occupying nation with opposing values. The 2010 reproductive rights provisions matter because the states can choose different provisions for abortion financing and service availability through the insurance exchanges and Medicaid programs. There is also specific language to protect clinicians who do not want to provide abortions, but no language protecting those who do. This is another example of unequal rights in the land of the not-so-free. The most onerous task is the mandate to attach a separate premium for abortion costs and to bill it as an addendum to the exchange plans. This seems like a lot of work for the estimated $1 additional cost per eligible woman, but that may be another way for the federal government to discourage abortions. What is next, wearing the letter A on our blouses? The shame attached to a common birth control method and often medically necessary procedure wastes a lot of resources that could be better spent on improving primary care across the board. For example, building a robust sex education program into the school system and providing contraceptive options to the sexually active population.
There will be other issues the states will argue about for health care reform implementations, but I thought we would start off with the most litigious and now the healthpolicymaven is signing off with condom in hand.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

High Risk Medical Insurance Federal Mandates

Comparison of State High Risk Medical Pools to the Federal Mandate for Pre-Existing Condition Insurance Plans or PCIP's
Recently I had the opportunity to listen in on the nonprofit Commonwealth Fund webinar about how state high risk insurance pools compare to the recent federal mandates for Pre-existing Condition Insurance Plans. The federal PCIP plans are a transition into the nationwide health care reforms mandating all people are covered regardless of their health and without waiting periods for medical insurance. The federal PCIP program started in July 2010 and runs to January 2014, when the national mandates for all insurance plans are slated for activation. This article addresses the plan differences and identifies which states have existing publicly managed health care plans for individuals the insurance industry didn’t want to serve, the uninsurable. Hallelujah, for all of you folks with real health problems, somebody cares, and you can thank the government.
Federal Mandates for PCIPs
The federal PCIP regulations require that all insurance plans be offered without waiting periods for pre-existing conditions, as I have previously reported. They also mandate that these individuals may not be charged a surcharge premium for their risk, in other words you can’t discriminate based on someone’s health. The maximum out of pocket cost for covered medical services per individual under the federal plan is $5,950 per year. The coverage must be nationwide, which probably means some insurance companies will not participate in the plans, which is fine. In order to be eligible for coverage under the federal plan, you must have been uninsured for six months. The federal plan does not offer a high deductible medical plan option of $5,000 for example. State high risk pools are not impacted by the health care reform mandate as they are not insurance companies or insurance plans, but nonprofit self insured funds.
States with Existing High Risk Medical Pools
Wisconsin-WHIRP
The information in this analysis comes from a presentation by Amie Goldman, CEO of WHIRP or Wisconsin Health Insurance Risk Pool. The oldest high risk pool for medical insurance is the State of Wisconsin’s, started by the enterprising cheese makers in 1980, which provides medical coverage for 18,300 participants. Their composite premiums are equal to the private market rates for medical insurance in their state, even though they insure the “high risk” people. Also since they are a nonprofit entity, they do not have to pay the state insurance premium tax, which is an administrative saving. The monthly premium for a 50-54 year old is a mere $277, significantly less than other states. In terms of what their participants want for coverage, they prefer the first dollar benefits. Wisconsin has not noticed any adverse selection, where someone signs up, gets their procedure done, and then dumps the coverage. Wisconsin also does a lot of outreach to health care providers and benefit specialists (insurance agents) to promote their plan. Their director did state that low income folks are still more likely to be uninsured (no kidding, let’s see we'll pay the electricity bill or the insurance). Essentially the chronically uninsured are not able to afford to pay for the premiums (poverty sucks).
New Mexico-NMMIP
The information in this review was presented by Deborah Armstrong, JD, director of the New Mexico high risk medical program. Since New Mexico is a less populated state, they only have 8,200 people enrolled in their high risk health care plan. According to their director, their most popular plan has a $500 deductible. Of their population, it is expected that 1,000 will enroll in the federal high risk pool. Their premium rate (cost) for a 54 year old person is $495 per month, which is less expensive than the new federal risk pool. New Mexico provides financial subsidies for low income people enrolling in their high risk health care pool. Administratively they do promote their product and recently AARP did a mass mailing about it. The state also pays a broker fee to encourage insurance agents to market the program.
Washington-WSHIP
Washington State has had a high risk medical plan since 1987, which basically covers all of the people who the private insurance sector did not want to cover and those who can afford the premium. The plan almost evaporated in 2000 due to financial problems at the state and federal level, but with some revisions, it still exists today. And Washington State was selected as the administrator for the federal interim plan or PCIP, until the 2014 health care reforms are fully implemented. The Washington State pool is funded by assessments on insurance companies, based on their premiums charged to customers. Premiums charges to medical pool participants are allowed to be 10% higher than market rates and cover 33% of the pool’s claims. The rest of the plans cost is paid by insurer assessments and there is no state revenue funding. According to Washington’s WSHIP report, about 5% of applicants for market rate medical insurance are rejected and of those, 20% have the resources to enroll on the state plan. According to the 2009 annual report of plan performance, the top diagnosis claimed were all cancer related. For pharmaceutical charges, 58% were HIV/Aids related and these represented 9% of the top prescription drug categories of expenses. Washington’s plan is split into Non Medicare and Medicare Eligible products. For purposes of this analysis, the focus is on Non Medicare products. Since I have already used the 50-54 year old age group for pricing, I am also illustrating that here, because at this age it is more likely medical conditions will exist that may make those persons ineligible for market rate insurance. Monthly premiums for a non smoking person in this age bracket would pay $986/month for a $500 deductible health plan and $476 for a $2,500 deductible health plan. Overall enrollment in Washington’s risk pool was 3,578 people in 2009.
Federal High Risk Medical Plan Rates
$500 and $2,500 deductible plans
Child only premium-$324/$161 for nonsmokers(straight off the federal register)
Child only monthly premium-$327/$162 for smokers (By looks of the small premium difference thankfully there are not too many kids smoking.)
Youth to age 24, nonsmokers, $377, $177 and for smokers,$431 and $207
Age 25-29, nonsmokers, $423, $200, and for smokers, $489 and $232
Age 30-34, nonsmokers, $489, $233, and for smokers, $566 and $271
Age 35-59, nonsmokers, $567, $273, and for smokers, $657 and $316
Age 40-44, nonsmokers, $671, $328, and for smokers, $784 and $382
Age 45-49, nonsmokers, $822, $402, and for smokers, $952 and $464
Age 50-54, nonsmokers, $986, $476, and for smokers, $1,143 and $556
Age 55-59, nonsmokers, $1,157, $563 and for smokers, $1,342 and $653
Age 60-64, nonsmokers, $1,355, $655 and for smokers, $1,577 and $769
65 Plus, nonsmokers, $1,355, $655 and for smokers, $1,577 and $769
Conclusion
The majority of the states (36) have tried to address the “at risk” population of people with serious medical conditions who are unable to obtain medical insurance, which drastically impacts their ability to receive adequate medical treatment. For information on what your specific state is doing, go to the insurance commissioner web site and look for State High Risk Medical Pool or something similar. Or call the customer service number of your state's insurance commissioner’s office and ask about it.

The Brave New World of Accountable Care Organizations

Brave New World for Health Care in America
Recently I attended a health care conference, sponsored by ECG Management Consultants, on the impact of accountable care as mandated by new government regulations for quality and transparency. An accountable care organization is a clinical group that receives a patient management fee from Medicare in exchange for improved patient oversight and quality standards. In short, this is pay for performance, not only for procedure. All of the panelists at the conference were in agreement that the health care paradigm has shifted irrevocably. There was much discussion around organizational adaptation for integrating quality measures in reporting and contracting, including one from a clinician in attendance, who decried the poor reimbursement for solo primary care practitioners. Essentially he was told that only clinicians whose model meets the new requirements for reporting and care metrics will be able to adapt. Wow, pinch me, did someone running a health care organization really say that in public? This is definitely the first time I have been in a conference where all of the experts were in agreement and publicly stating the old model for doing business in health care is dead, which is to treat and bill for services, based on usual customary and reasonable charges. It is no longer adequate to do a good job with your patients; you have to be able to demonstrate that with your quality metrics. Certainly some clinicians will choose to retire, others will join larger clinics to be able to compete, and some will be the leaders in this adaptation. The Everett Clinic comes to mind, a leader for decades in the provision of affordable care to a diverse patient population, and with excellent quality measures, as reported by Leapfrog and other quality watch dogs.

The medical community, as represented at the conference, is anxious to adopt a new compensation model beyond the fee for service practice and though it will be a process of adaptation to include medical home and other primary care provisions into a reimbursement model, it is happening. The accountable care organization provisions encourage health care entities to reduce waste, provide measureable improvements in care, and improve the end stage of life care process. The first article I wrote in my health care column in 2007, was about end-of-life-care and the impact on the patient as well as the cost to society, with my brother as the benchmark for the shift away from prolonging life regardless of quality.

Conference speakers from Monarch HealthCare, Brown & Toland Physicians, The Everett Clinic, and Premera Blue Cross were in agreement on the following principles derived from the recent health care reforms:
1.Health care decisions will be driven by the individual and less so by the corporations.
2. We are going to have to provide a lot more care to an aging population for less money.
3. The system has to make meaningful cost management changes.
4.One of the big costs that need to be confronted is inappropriate end of life care due to the absence of medical directives, lack of palliative care programs, and general lack of awareness on the part of patients.
5.Other cost vectors that need to be controlled are reducing unnecessary procedures, allocating technology more efficaciously, and reducing excessive administration costs.


Government Processing Speed
Concerns raised by this group of health care administrators include the speed with which the Center for Medicaid Services, CMS will be able to process all of these changes. It took a year and a half for them to measure the Everett Clinic’s results in a demonstration project. Since the scale and degree of health care changes are significantly greater with the 2010 health care reforms, one has to wonder how many years it will take for the reporting to occur, let alone system integration.
New Medical Model
The model for an effective health care delivery organization will have to include these criteria to succeed in the new health care environment in the United States:
1.Clinically integrated multispecialty physician networks
2 An economic model to manage risk and deliver patient value
3.Immersion in evidence based medicine
4.Successful communicators of their value
Benchmarks for America’s New Health Care Program
The United States’ ability to compete for goods and services on a global scale demands a more efficient health care system, because we cannot continue to spend 20% more than everyone else for health care. Several countries have managed private insurance programs for the provision of health care including; The Netherlands, Switzerland and Taiwan. The USA would be wise to observe how these models function and to adapt best practices. One thing that is clear, despite the catcall for subsidizing health insurance costs, these other countries provide subsidies, up to 40% of the premiums, depending on the income level and location of the enrollee. So to all of the whiners who criticize insurance subsidies for the middle class, if you want an inclusive national medical program using private insurance, this is a mandatory element, so get over it! It is in the best interest of everyone for the focus to remain on how those dollars are spent and on the value we are getting for improved health care, for example, managing hypertension to reduce the incidence of kidney dialysis, which costs a minimum of $50,000 per patient. If we improve our health care model and deliver care more efficiently we can bring down the relative per capita cost of health care over time.

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Mandate

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Initiative
According to an article in the New England Journal of Medicine, 57% of private employer plans are ERISA self insured plans and are exempted from many of the 2010 health insurance coverage mandates, since these plans are not considered insurance. This means most of the large employers out there will continue to manage their own health care programs as they have in the past. Smaller employers will be the ones most impacted by the insurance mandates and often, they are the least able to pay. The federal subsidies help some small employers, but if you have over 25 employees you are required to provide the expensive first dollar coverage and pay a significant portion of the cost. Perhaps the small employers will elect to pay the penalty rather than play in this pool. It is also worth noting that a lot of start-up companies and nonprofit organizations fall into this size category and their funding is quite restricted.
Cost to Produce the Baseline Surveillance
The impact on the health plan’s cost will of course be a factor in the hiring of new employees. Though it is illegal to discriminate against older workers, one has to wonder why a small employer wouldn’t consider age when it would impact the cost of their medical plan. Even under the Obama reforms age is still a factor in establishing a community rate for the price of a health insurance plan. Yet another nail in the coffin for anyone who is over forty and looking for work. As a student of government policy making I am wondering if the unintended economic consequences were fully considered with this 2010 health care mandate for small employers to buy expensive front-end loaded insurance for their employees.
Encouraging the Desired Effect
I favor the carrot incentive method much more than the punishment stick and keeping the tax deductions for health and welfare plans is critical to employer sponsorship, as well as keeping some flexibility in plan design so the smaller businesses, both for-profit and not-for-profit can participate. The federal subsidies apply only to very small employers with 25 or fewer employees and are targeted to firms with 10 and under workers, which is understandable from a budget standpoint. It is telling that the government considers small business only those with less than 50 employees (the standard most likely to be adopted by the majority of the states), who are exempt from the penalties for not providing medical insurance plans. In the private sector, employers with less than several hundred employees are considered small and in my insurance career, several companies considered all firms with less than 2,000 employees to be small employers. This difference in standards is based on the volatility of the claims performance data and the management required in order to replicate a similar outcome for the smaller firm versus a larger client.
Wellness Care Mandates
Though I understand the importance of providing primary care, which means early detection of costly diseases like high blood pressure (which is a precursor to kidney failure and cardiac problems) through annual exams, perhaps having them provided by insurance companies is not the most effective method. The insurance industry is deft at managing large risks and not at providing disease surveillance or wellness. Any efforts to do so by insurance companies involve add-on commission based products that are provided through a third party and generally not well integrated into program performance. You can bet that plenty of insurance agents are selling wellness programs now that the coverage is a government mandate, but what is the efficiency of this model, other than to make more money for the insurance industry?
Better Way to Provide Wellness Services
Another way to provide disease audit and management could include using public health nurses or clinics to do the surveillance, which would protect the privacy of the individual and provide key surveillance information for a community trying to manage its health care. Since large employers may already use on-site clinics to provide the wellness services, the small employer sector needs a better model for identification of at-risk employees. Also, the public health programs need an infusion of capital and this would be a great way to take the old “school nurse program” and create a community nurse program nationwide. As someone who went through a Minnesota winter with untreated bronchitis I wish there would have been a school nurse in my high school. I would love to see a cost benefit study on using public health programs and federally qualified clinics to provide the wellness services versus the insurance industry products. Everyone likes to complain about the inefficiency of government programs, but the financial support of federally qualified health centers through federal grants has proven so effective it has been reauthorized by three presidencies. Public health programs have been on the front lines in addressing health risks for a hundred years. These programs are effective and they don’t require sophisticated and costly marketing schemes to pitch their results, but they could use your advocacy.
For those of you who have a fear of public health, I can attest to the efficacy of the program as I have been a customer of Seattle Public Health on many occasions, for my travel immunizations (they have the best travel clinic), for primary care treatment when I have been without insurance, and for referrals to other medical facilities, when no one in the private sector would see me. At least with the Obama protocols many of the uninsured will have medical insurance, which will at least enable them to get a private sector physician to schedule an appointment. The Obama health reforms are creating a new baseline for health care design and reporting and maybe in the long run it will empower consumers.
For more information on how the states are reacting and their regulatory authority for the federal health reform mandates, read the September 15th article in my contributing column for the life sciences newsletter of the east coast consulting group Tag44.com at http://www.tag44.com/newsletters/ls%20newsletters.asp?cat=lifescience.
This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Evidence Based Planning and the Obama Protocols

Evidence Based Planning: How it Impacts Health Care
EBP: What it is
Evidence based planning is the catch phrase of the health care reform movement and this article explains what it means and how it is applied in health care processes. The Institute of Medicine or the IOM defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge”. Evidence based planning is harnessing the enlightenment gained from sharing scientific and medical practice information and using it to optimize clinical and operational procedures to improve results. The health care reform mandates in 2010 have provisions for increased transparency and optimization of service delivery, which can only be achieved by deploying the best practice protocols by diagnosis, whether it is heart disease or diabetes through the evidence based planning process. Certainly the words “best practice” are not offensive, but the beast rears its head when someone other than the local practitioner suggests a change in practice or patient protocols. However, this method of protocol review is an ongoing drama that has been and continues as the singular best method to reach out and impact treatment patterns. Large integrated health care organizations like Kaiser, Group Health Cooperative, or the Veterans Administration already have working committees who meet regularly to review data, test protocols, make recommendations for changes, and deploy the innovations throughout the organization. Hospitals also have multi-disciplinary committees who meet to figure out how to enhance patient outcomes by reviewing and adopting the best data driven practices and not all clinicians are happy about changing their patient practices as a result of the scrutiny.

Health System Impact
Evidence based planning is the practice of critical review of scientific literature (study data) to obtain advances in medical care protocols and then developing a method for localized testing and adoption within a health care facility or system. EBP is a process, not a single product driven task. The act of planning is a verb and applying best practice evidence in that process enhances institutional performance metrics. This means that patients who are the beneficiary of best practices live longer and with fewer complications than those who don’t, by a population standard.

Reducing the Patient’s Chance of Dying
As an example, when I was working on my MHA degree I took an evidence based planning course at the University of Washington School of Public Health and our EBP project reviewed data on Secondary Myocardial Infarctions (heart attacks) to develop a plan to reduce the likelihood of the second heart attack. We reviewed a significant body of information, including several dozen peer reviewed articles, and a European study which had measured time to treatment and long term prognosis for myocardial infarction patients . In our EBP project we learned that if patients registered in a follow-up program, especially a national database (like the Minnesota Heart Institute Registry), saw a cardiologist for medication management, and obtained appropriate medication, their chances of a second heart attack were 6% less than patients who did not follow these protocols. Our research included a comprehensive review of 40,684 admissions in Pennsylvania hospitals from a study in 1993 . The study cited an estimated cost savings to the Pennsylvania Medicaid program was $71,970 just by improving compliance for prescribing and administering beta-blockers. We also discovered that MI patients who obtained their three month follow-up visit were 57% less likely to die than patients who did not come in for their check-up. A retrospective cohort study (means they are reviewing historical patient data to draw conclusions) in Scotland, showed a significant difference in patient outcomes post discharge if they were treated by a cardiologist. Now it doesn’t take a rocket scientist to figure out this is a huge difference in performance, which has a significant impact on the cost of health care, when you consider that the Association of Health Research for Quality (AHRQ) estimates that 50% of Americans die from heart disease.

Implications for Medicare, which is the single largest cost driver in US Health Care
Heart disease is expected to remain the leading cause of death for the USA until 2020. By improving the outcome of cardiac patients we can save literally, millions of lives, and this is accomplished by evidence based planning. The beta-blocker protocol alone could save state Medicaid agencies 3.7 million dollars in a single year. This is an example of how government policy, drives reimbursements that impact which treatments patients receive, which can be life saving as well as monetarily more effective.

Another example of the application of evidence based planning was in 2005, when Medicare created incentive reimbursements ($6,000 per patient) for the administration of the drug tPA within three hours of a stroke, because patient recovery and mortality were significantly improved by this process. This was a way to get the attention of hospital administrators and improve surveillance and dispensing of this drug within the window of time to provide the biggest clinical impact.

Currently Medicare has demonstration projects reviewing how to improve chronic disease management for diabetics and other disease management programs, to improve patient management and Medicare health system management.

Why We Want Evidence Based Planning
The value we will get for our health care contributions, whether they are premiums, tax allocations, or fees for direct services are directly affected by the efficiency and cost of services in any health care system. It is in our best interest in terms of patient mortality (death) and morbidity (other complications) to seek care from institutions who are openly seeking to adopt the best practices world-wide for the management of your condition. The 2010 health care reforms under the Obama Administration specify and encourage the communication of performance metrics and the adoption of best practice clinical protocols to give you the best value for your money. Sounds great, so why isn’t everyone excited about this process to save money and improve our clinical outcomes when we have treatment? The conservative think tank Heritage Foundation, criticizes the Institute for Comparative Effectiveness, created by the Obama reforms to use population based research, as I previously explained in my cardiac example, as a bureaucratic intervention. This is not an accurate statement as evidence based planning is a science based discipline reviewing published studies under the Cochrane Central Registry of Controlled Trials and Medline Database among others to discern performance difference of significant impact on populations. The Institute for Comparative Effectiveness will review these science findings, make comparative information available to clinicians, insurance companies, and patients as a part of enhancing communication about patient procedural outcomes and system processes. The agency will coordinate with the National Institute of Health, NIH and Agency for Health Research and Quality, AHRQ as well as other expert sources to assimilate, measure, and distribute data on optimizing medical system performance. Why wouldn’t you want to have a resource to cull and present current international data about disease management and procedural outcomes? Sure it will cost a bit of your tax dollars, but a lot less than the ordnance in Iraq or Afghanistan.

The Institute for Comparative Effectiveness
The real value in the Institute for Comparative Effectiveness is the initiative in linking economic cost benefit analysis to health care delivery protocols in order to reveal the most efficacious methods. This means cutting waste, reducing unnecessary procedures, resourcing facilities appropriately (we don’t all need the DaVinci surgical robot), and improving surveillance of illness to slow disease progression. Yes, it will put the spotlight on health care suppliers, insurance companies, and other providers, but if we really intend to address the grossly high cost of the United States health care system(more than any other country and with poorer results in many areas), this is necessary. The folks who are using the scare tactics about evidence based medicine are trying to get a toe-hold in the “old each-practice-doing-what-it-wants” method of dispensing health care. That process is too expensive and the degree of variations in dispensing health care in this haphazard fashion do not create the same proportion of patient improvements as adopting optimal best practices for a society. Medicare did the right thing by rewarding hospitals who were administering tPA for stroke victims within the optimal window for efficacy and hopefully this new institute will help identify and spread other improvements to American health care as well. This is a first step in some analysis on effective cost cutting measures for United States health care.

What you can do
Use your fingers and do some research on the internet, go to reputable sites like AHRQ or NIH and educate yourself about your condition before your follow-up appointment after your initial diagnosis. When you meet with your clinician, ask about best practices and see what they say. If you are uncomfortable with the response, ask more questions, or consider getting a different clinician. You can have an impact on your health and your wallet if you do a little bit of research and ask the investigative questions. And to those who say evidence based planning is bad, I hope you visit a health care facility that isn’t using global best practice protocols. Good Luck!

This article was written by Roberta E. Winter, MHA, MPA, a health policy analyst in Seattle, Washington and may be reprinted with her permission. 7/13/2010