Friday, May 12, 2017

My Analysis of the ACA and the New Healthcare Bill

There has been so much going around, as always I have a hard time finding a spot to begin. I've been researching the new healthcare plan, and it is not a good read. There are a few things that I find particularly disturbing. As always, these laws are drafted, and nobody probably bothered to ask themselves "so, once this is in place, exactly how is this going to work?". Has anyone thought of the practical side of things or thought to put protections in place to keep chaos from erupting? I think not.

Let's address the preexisting condition issue. I remember how the healthcare system worked prior to the ACA and after, after is better. If this law is passed, what is to stop an insurance company from deciding any expensive medical issues you have are due to a preexisting condition? Where would the proverbial burden of proof be? With the insurance company? Most likely it would be both with you and your doctor to have to PROVE any conditions you have are not due to a preexisting condition to them prior to them insuring you or paying for care. How far back into your history could they go? Do you have the records to refute it? Before you tell me that they wouldn't do that, I can tell you prior to the ACA, they had, and would still continue to do it if allowed.

Speaking of coverage, let's talk about gaps in coverage, or continuous coverage. Way back when prior to the ACA, when you switched insurance companies, the new company would demand you provide a "certificate of continuous coverage" before they would accept you on to their plan and provide you coverage. Obtaining one was not always easy then when accurate records were kept, how about now? Do we honestly think that insurance companies have kept accurate and detailed records of our coverage on their plans over the past 7 years or longer? Especially if we switched providers? Do we have records of which companies had covered us and the dates of when? If we worked for an employer that provided coverage and they switched plans or companies, do we have records of those dates? What happens if we don't? What happens if an insurance company withholds that information, or refuses to provide it in a timely manner to the new carrier? Where does that leave us? It's happened before.

There is another caveat to this as well; when having to provide proof of continuous coverage, publically funded insurance did not count. Many if not most large insurers would not consider a strictly Medicare, or Medicaid plan as a "legitimate" insurance company or plan to count as continuous coverage, so if someone was on those plans and didn't have any supplements, it was considered a gap in coverage and was used to deny coverage and services. Anyone thought of asking if this is going to be the case again? Probably not.

Oh and by the way, if you can't prove there aren't any gaps, you get a 30% surcharge.

There's another thing that everyone seems to be missing, and that is the allowance of insurance companies to charge up to five times as much for older adults as opposed to three times which is what it is currently now. When we see this in the news we often think of INDIVIDUALS sitting around having to pay more, and gee they talk about those folks getting tax credits to help them, so nice isn't it? What nobody says and nobody is addressing is the effect this could potentially have on BUSINESSES! See I'm sure insurance companies as a whole get some good dollars from individually issues insurance plans, that is not where their profits lie.

Their profits lie in plans they sell to BUSINESSES! The deeper pockets lie with BUSINESSES! This plan give the insurance company permission to jack up premiums! Let's face it, if you start increasing premiums for individuals too much, you will probably start to loose customers, but hey, businesses and corporations have deeper pockets, much deeper pockets, and they would not be in a position to cancel their plans as an individual would. Some larger companies would be able to eat the costs, and have to raise the premiums on their workers. Would this make them less likely to hire older or more at risk workers? Well, they officially can't do that, but would it be in the back of the minds of hiring managers? Would they start giving harder performance evaluations for older workers or try to push them out? It's hard to say at this point. What will this do to small to medium sized businesses? This could hurt them financially, deeply, and it might destroy some of them. Oh, but wait, under the new act, companies can offer plans that are cheaper with lifetime limits on expenses, to get a lower premium! So if someone has already reached their lifetime limit, even if they pay for it under an employer that selects this option, they would  not have coverage.

What exactly could the amount of a lifetime limit be? Any regulations or restrictions about that? For example: do you realize an insurance company could arbitrarily decide for a plan to $50,000 lifetime limit? That seems like a lot, but really, that would probably barely cover one emergency incident, illness, or surgery. Do doctors visits, and medications count towards the lifetime limit amount? Could they? Would an insurance company be able to do that? Who could stop them under the new plan? to put this in perspective, I'll break down some common medical costs (without insurance):

According to the National Heart, Lung, and Blood institute a typical emergency room visit would cost between $150 to $3,000. Someone that has had a heart attack would likely spend anywhere between $30,000 to $200,000 depending on the course of treatment.

A sick infant's stay in Neonatal Intensive Care or NICU hospital stay averages about $2,5000 a day just to stay in the hospital, that does not include consultations or procedures, and that adds up fast, a child could reach a lifetime limit prior to ever even leaving the hospital.

One other big thing is restricting funding to Medicaid and putting them on a "budget". Um, how did we determine that they needed to be on a budget? Was there any audits? Research into their financials as to how they are spending their dollars? Any mismanaged funds? What empirical, objective, detailed evidence do we have that this is the best course of action to take? I have yet to find any.

It is disturbing to me to say the least.

One other thing I find interesting, there has been little to no statements from any of the larger healthcare carriers on any of this. No reassurances that they will try to help anyone maintain coverages or benefits despite the laws. No plans on how they would act or implement these new changes, as a customer I find that disturbing as well.

Tuesday, February 21, 2017

Arizona's SB 1317 Special Education Teachers

I was originally made aware of this bill via an article from the New Times. The link to that article is here:

There are so many things wrong with this, I do not even know where to begin.

Basically it states that ANY teacher can provide services and special instruction to ANY special needs student in lieu of a teacher that is certified in Special Education, oh but wait, the Special Education teacher will be able to review what is going on and tell the teacher who is not certified what to do. So basically not only does a classroom teacher have to work with typical students, because, hey we just don't keep them busy enough, let's have them do the Special Education teacher's job too, how could that fail?

I'll tell you how, because this in one form or another was being practiced by Deer Valley Unified School district. They had my son in a typical classroom, and most of his teachers struggled with this very issue. IT DID NOT WORK!

The result? I had one of his teachers look at me and tell me that my son was "normal" with some behavior problems. Can you imagine having to sit and argue with a group of people that your child is not normal? I should not have had to, let's face it, nobody contradicted her, even though we had a stack of documentation a mile high of his medical history and THEIR PSYCHOLOGICAL ASSESSMENTS that proved OTHERWISE. She didn't get it, and didn't want to, I don't blame her really, it's their screwed up system that put us both in that position in the first place, she just wanted to teach, and it was quite obvious that she was not willing or able to accommodate him. To be honest, he was not placed appropriately,  and it was damaging for them both. They set us up to fail, who knows whether or not it was deliberate or intentional, the results were the same.

I know it sounds like a good model, trying to have special needs children in the classroom with their peers, as parents we are sometimes so desperate for our children to fit in, not to stand out, and feel "normal" but honestly, that is about us as adults, what we want what we need, what looks good, not necessarily what our children need or what is perhaps best for them, but it is easier and cheaper for some school administrators to convince us that by doing this or that, our child has a hope of fitting a mold, and they can save money by not having to pay a better educated specialist for their time. It is wrong.

What is so bad about giving children with Special Needs a space where they function better? What is the problem in them working with someone whom is better equipped intellectually, professionally, and whom has more resources? There isn't one, other than potential costs, it sounds like it would, it sounds like it would be logical, but I challenge you or anybody to show me some EMPERICAL, OBJECTIVE evidence, studies, assessments, numbers, something that backs this up, not just because it sounds like a good idea.

Yes, our children have a right to an education, why do we assume that translates to our children having to be placed in a classroom with their peers? What does one have to do with the other?

I would like to also address some commentary made by  Deer Valley Unified School District special-ed administrator Denise Lowell-Britt. It wasn't very clear, but she apparently used some sort of weird medical analogy, like if your PCP sees you have a cardiac problem, they send you to a cardiologist, and then they coordinate treatment or something and you stick with your PCP for everything else unless he needs advice from the Cardiologist. If you have had or known anyone that has had to go see a specialist for any known medical problem, you know that THIS IS NOT HOW IT WORKS!

I'll keep running with this analogy, as someone who has had family members with cardiac problems and as a former Social Worker that had patients with cardiac problems. When you develop a cardiac problem, you go to a Cardiologist who does an assessment and then if you have a problem or issues, they decide on a course of treatment and then THEY FOLLOW YOU personally, they set appointments for you in their office, they arrange for tests, they prescribe medications, they do NOT send you back to the PCP with a list of instructions on how to treat your heart condition and expect them to follow it, or check in with them every once in awhile, or supervise what they are doing making suggestions. In fact if you have a problem, you will see the Cardiologist more often than you see your PCP. The only time they send you back to the PCP is if there is NOTHING WRONG WITH YOU from their perspective.

This type of commentary is not improving the reputation of the Deer Valley School District, they still have the reputation of being one of the worst places for special needs students to be. This commentary shows a lack of empathy for the students, and a general dysfunctional attitude that is pervasive in their system, I experienced it with my son, and I am sad to see that not much has changed since we transferred him to another district, where by the way, he became much more functional and successful because they were willing to meet his needs, not trying to get him to conform to theirs.

Unfortunately I believe this type of legislation will encourage others to do the same.  

I'll make some phone calls tomorrow and see where that goes.

Tuesday, January 24, 2017

Betsy DeVos

In the interest of trying to remain as objective on this subject I did some research. I have worked as a recruiter in the past, there are several aspects to recruitment and job descriptions, the one aspect I wanted to research was "Qualifications" or "Requirements. What exactly determines someone is qualified for a position? What separates them from other candidates? What are the minimum requirements for a job? All I could find for the Secretary of Education was a broad description of duties, no minimum job requirements. Interesting. I will admit in the interest of time, I have gotten the majority of my background information from Wikipedia, if you feel that I need to dig deeper, please advise, he is the link listing prior secretaries leading to their various backgrounds.

I asked myself, what would I do if I was asked to recruit for a position, how would I define minimum requirements for the job if there was no previous documentation? My answer is to look at the past individuals that have held the position and draw my information from there. There were some similarities which I could I would put as minimum requirements, some would or should be preferred. One is that everyone had a Bachelors degree, however only two had Master's degrees as well as two held Doctorate degrees as well, and the acting Secretary prior to inauguration day had a Bachelor's degree, a Master's degree, and a Juris Doctorate. All the prior Secretaries held degrees in one or more of the following subjects: Political Science, Government, and Sociology from well known universities. Betsy DeVoss holds a Bachelor's degree in  Business Administration and Political science from Calvin College, I have never heard of it, I am not sure what their academic standings are in relation to the degrees that some of her predecessors held from Harvard, Yale, University of Houston, and University of Indiana Bloomington.

What also struck me is that all prior secretaries held positions working with education in the public sector, as well as having either founded publically funded charter schools or having worked as their administrators. Betsy DeVos has not, she has been involved in political action groups and foundations in the education sector, but it appears she has not been directly involved in the administration of a school either pubic or charter, and has never worked in a position at any level involved in government or education other than working with private foundations and political action committees, in fact I could not find information that looks like she has served in the public sector at all, which in looking at past Secretaries, should appear to be a job requirement. That in and of itself should disqualify her.

Ok, that's my impartial view, on to my more opinionated one. She wants to open up public education to privatization, looking back historically, really, how often does that work well? Does she have a model or any objective information on how that would be beneficial? Not that I have seen. Let's face it, I highly doubt there are going to be a lot of private schools opening up in lower income neighborhoods to benefit those children. What makes her think a private school would do a better job  with public funds? If you funded a public school with the amount of dollars that private schools get per student, I'm sure that school would also improve too.

I can't really argue against choice of schools, for us it has been a life saver to be able to send my son out of district to another public school. If we had been able to have my son's needs met we would have stayed, what I had found shocking was their lack of accountability in the district, and I would have to ask myself how much worse will it be for parents like us if she is appointed?

We did look at private schools, a couple had a focus on kids with disabilities, one of the biggest deterrents for me in going that route was that we were advised  my son's IEP would be invalid, private schools are not held to the same standards for disabled students that public schools are. They are under no legal obligation to accommodate or compensate for his needs at all. Not to say they won't but they are under no legal obligation to do so, and there is little to no recourse if they do not. Privatization would definitely not serve well for children with challenges, and isn't the Department of Education required to serve everyone? I was also unsettled by her repeatedly answering that she would let "the States" make decisions on a variety of topics, which is really not what she would be appointed to do, her position would supposedly require certain decisions be made, not let the states do it for her.

Let's also mention the fact that some of the largest teacher's unions and organizations oppose her quite strongly, these are organizations she is supposed to ultimately work with, and they have in the past have successfully pressured Secretaries to resign.

That's it for now, however you feel on this topic, that is my opinion, info on how to call your elected officials to express your opinion are in a link provided in the prior post.

Monday, January 23, 2017

Want to make some calls???

There's a lot going around about different things and ways to call and make a difference with our elected officials. Below is a link to a good document that gives instructions and pointers.

I'm Back

Whoa, I see it's been awhile since I have posted, things got away from me but in this new era of uncertainty, I feel like I need to start posting again, because I'm pretty sure some politicians will start trying to take away funding and services again so I will.

Things have changed here as well, after much debate, arguing and banging my head against the wall, we decided to place my son in another school outside of Deer Valley School District. It was not an easy decision on our part, we did everything we could, including going to a school board meeting and speaking out about the lack of services and letting them know about their reputation in the Special Needs Community as being one of the worst districts to deal with. THAT did not even precipitate many changes for my son.

So, I, after some research, I found another school (I do not want to give the details in this public forum, nor do I want someone to be able to identify who he is). I had a couple of last straws, one being my son coming home from school, banging his head on the wall telling me he hated himself and he thought he was stupid on a continual basis, the other was him being continually assaulted by another student that was bullying him. My meeting with the principal did not go well, she looked at me and stated that she didn't want to use the term "Bullying" when discussing this situation, to which my reply was "Okay, how about we use the terms assault and negligence on your part?"

She then told me the aggressor was another special needs student to which I replied that she failed them both for both of them being in a situation in which one of them could be harmed. I asked her to explain to me how she thought it was beneficial and healthy for the other student to be in a situation in which he was able to harm another student if he could not control himself. I asked how would she feel if she was put in a situation in which she was going hurt someone and could not stop herself, what kind of stress would she be under, and what that would do to her self worth. Her reply? "I didn't think about it that way" For me, I just can't reconcile keeping my son in a place where someone in authority does not "think" that way.

It reminded me of a phrase that I saw online it's like "Playing chess with pigeons, no matter how good you are at chess, the pigeon is just going to knock over all the pieces, crap on the board, and then strut around acting like it won"

The good news is my son is in a much better place now, it took us awhile to work out a new IEP because the other one was so poorly written, executed and had little to no documentation. There were goals that were written when he was in kindergarten that had not been updated at all.

What we found is that in fact my son is a gifted learner (this was figured out in a week, as opposed to the old school whom never even noticed that this was a possibility), and while he doesn't test well on gifted placement exams, that is how he functions, we now have the documentation to prove it, and a terrific school that is willing to work with him on his level to address his needs. He excels in school work, and is performing 2 years above his grade level. He is happy, and has not once stated that he thinks he is stupid anymore. He scores extremely high on his AIMS test, according to their graph, he outscored most of the kiddos in his district, at times I have been tempted to send his old district a copy of his scores and tell them to "suck it", but I have refrained. He has been at this school for three years now.

As far as DDD goes, services for us have been a challenge with timing and the distances we have to travel to and from his school, but thankfully there has been no effort to reduce them.

So far, so good, I will do research on some of the political stuff coming out, I'll try to be as objective as I can.

Wednesday, August 21, 2013

Deer Valley Unified School District

I have had my challenges to say the least with this school district and literally fighting to get services provided for my son.

I have called several agencies, they seem to have a reputation for fighting with parents on providing services, I must say my own personal experience seems to validate this, especially for physical therapy.

Has anyone else had this experience with this district?

Tuesday, April 10, 2012

The Fight for Xopenex

If you are not familiar with this medication, it is an inhalant very similar to Albuterol, similar BUT NOT THE SAME. I had a very hard time convincing United Health Care (UHC) of this fact. I had to fight this one all the way, and I figured I would post how I did it to help anyone in the same boat. Lucky for me, being stubborn in these situations pays off.

My son had been taking Xopenex since he was in the NICU. They had attempted to use Albuterol, but his heart rate and blood pressure went way too high while he was on it, so they gave him Xopenex and he responded much better. He was on it last year, while it was not on the formulary, his doctor was able to get it authorized with a medical review. Then this year rolls around. My son's doctor goes to get it authorized again using the SAME process, and UHC denies it, sending a letter home to me stating that it was not on the formulary, and that they would not authorize it because Albuterol was an acceptable "therapeutic alternative" and that was on the formulary list. I called, and spent approximately two hours on the phone trying to figure out what was going on. I explained to everyone I spoke with that these are very DIFFERENT medications, and Albuterol is NOT an acceptable alternative in my son's case, and the reason why. I was able to file an appeal to this decision over the phone, stating the differences in the meds, and the fact that it was authorized the previous year (to be honest, I could not find anyone to speak to on the phone that had a good explanation as to why it was authorized the previous year and they were currently denying it).

It was denied again. Nobody could explain why. I had to spend over an hour on the phone again before I finally could speak to a supervisor that was able to review the case and the notes. He reviewed the documentation and was able to pull up notes from the previous year. He mentioned that perhaps the appeal got denied because it did not reference these notes directly (even though I had instructed the previous rep to do so), so he wrote another appeal for me citing the specifics. I also requested and received from my son's doctor a copy of their notes stating that Albuterol has caused my son to have "tachycardia" (heart rate rises to unacceptable levels outside the normal range) when he has taken it in the past. I also sent a copy of these notes in as well.

It got denied again. The supervisor I had been working with called me to tell me it was denied, I asked to be put in touch with the person making the decision to discuss the medical concerns I had about this turn of events, but I was told it was an "administrative" decision, and not a medical one. I was a bit shocked, he indicated that he had attempted to get this case reviewed by a individual with a medical background, but they refused to do so, stating that this was a case in which they felt that they didn't have to do so, and they were only making an "administrative decision", and advised me of my appeal rights. I called one of their "resolution specialists" and attempted to demand this go under medical review, they refused to do so repeatedly, saying basically they won't review it medically because they didn't think that they had to.

I filed an appeal with the Arizona Department of Insurance, as well as a complaint about the fact that they were refusing to have my son's medication situation evaluated by a qualified medical professional, just administrators. I submitted my documentation of my experience with UHC, and the notes from my son's doctor, as well as the form my son's doctor had filled out the previous year in which UHC had used in their initial authorization of it.

The Department sent this case to an independent reviewer to make a medical determination, they overruled UHC stating "This patient has exhibited tachycardia in response to treatment with racemic Albuterol but has tolerated Xopenex for a number of years without unwanted side effects. The literature supports the use of Xopenex for patients with asthma in general and in particular those with undesired side effects from treatment with Albuterol. As such Xopenex is not unproven in this patients care  and is medically indicated. Therefore, the Insurers denial should be overturned"

It took a while, and a lot of aggravation but we finally got what we needed. It is unfortunate, if UHC would have just followed the same procedure they used the previous year, they would have saved themselves a lot of time, and effort. If they would like to reduce their costs, I would suggest better training their staff, even cutting my call times from two hours to one hour would help their bottom line (there were several of these calls), not attempting to deny medically necessary medication, in fact they wound up INCREASING their costs in terms of administrative work and manpower. Very shortsighted of them.