When A Word Is More than Just A Word

Language is important. Every issue, situation, and event has language to communicate the story around it. Healthcare as an issue is no different. For example, “chronic illness” is a common hashtag, but you will rarely see the “illness” part used in my posts. That is intentional. I prefer "condition". There are negative connotations like victimization and helplessness that come with "illness". I try not to write to that.


Language may be part of what's wrong with the discussion around health and healthcare. During the last presentation at the Lown Institute Conference this year, Dr. Viktor Montori pointed out that we talk about healthcare as an “industry.” It’s such a cold, harsh word to describe a world whose goal is something as vibrant and vital as life. As Dr. Montori said, if doctors are not treating patients with kindness and care, they are missing the point.

I agree, and I am lucky that all of the doctors I see more than annually do treat me with care and kindness. But I would like to take Dr. Montori's concept a little farther – to the insurance companies, researchers, and yes, the politicians.

Healthcare is unique in the pantheon of political issues. There is no other that poses inevitable mortal risk to so many, which gives it intimacy and urgency. When we were going through the attempted repeal of the ACA last year (twice!), I stayed up to watch the votes because I would not be able to breathe easy until I was sure of the outcome. Even now, I wonder whether those in the administration who continue to chip away at it or those in Congress who won't bring stabilization bills to the floor consider that they are literally sentencing theirs or their boss's constituents to death. People die when they can't get the medical treatments they need.

I know I’m using harsh language, but this is reality and to use more diplomatic language is to lessen that reality. And when people are dying, what right have we to make it easier on those making such impactful decisions?

I think we can change that language. George Orwell said, "But if thought corrupts language, language can also corrupt thought."

He was right. Language is powerful. The words we use reflect how we think. They can reveal whether someone is an optimist or a pessimist, their unconscious biases, and even where they've lived.

If we change the language we use to discuss healthcare, we can change the way we think about it. We can make it so that the people who make the decisions that affect our lives on such a fundamental level start seeing us not just as a policy or the price of a drug, but as us – people just like them, with lives and families, triumphs and setbacks, who feel love and hate and fear and curiosity. They are us but for faulty biology. If they can realize that, we will find their empathy, and empathy is what creates common ground.

It's going to take a while. The Oxford English Dictionary usually waits for 10 years of evidence of usage before it adds a word to the dictionary. But as many of us as there are, and as prominent an issue as healthcare is, I don’t think it will take that long. We should start small, maybe by deleting “industry” from the discussion. If we can stop talking about it in terms of profits and losses, we stop thinking about it in terms of profits and losses. Which might open the door just enough for empathy to fill the gap.

It's Open Season! - How to Pay Less for Medical Expenses You Need

Still hunting wabbits . . .

Open season is still on the horizon, so I thought I’d offer another couple of health plan components that you may be able to choose from, the Flexible Spending Account (FSA) and Health Savings Account (HSA). Pretty straightforward, I thought, until my dad (the retired healthcare exec) laughed at me. Maybe not. There are several subtle and not so subtle differences between the two options, but they are still easier to understand than most health insurance policies.

In a nutshell, FSAs and HSAs help you budget for your medical expenses with money that isn’t subject to income or payroll taxes. You usually can’t get both unless you are eligible for a dependent FSA (not discussed here). But if offered, you should take one or the other because, as Dad always pointed out, if you don’t take advantage, it’s like paying 133% when you don’t have to.

The one thing that may limit you on this is monthly overall expenses since once you make your contributions, withdrawals for non-medical purposes come with a penalty. I would love to be able to max out my contribution (I’ve had each before), but often I need cash on hand to pay for other non-medical expenses. So, I try to get as close as I can to the total out of pocket maximum for my plan that year, as much as I can without limiting the ability to pay other expenses. I am also lucky that, if I do an annual wellness check, my employer will contribute a few hundred dollars (that doesn’t count against the maximum contribution limit). I get into what this means below.

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Often, you have an idea of what your annual medical expenses will be based on the previous year: regular medications, number of doctor visits, medical device supplies, whether you are going to need planned surgery like for cataracts, or dental work. Use these estimates to come to an annual total and divide by the number of paychecks you receive per year for the amount of your contribution per paycheck, and see if you can afford to lose that much at a time. If not, start subtracting until you reach a contribution you can afford.

Then, if you have a choice, use our list to decide which option is the best fit for you. I will highlight the biggest differences between the two.

Flexible Spending Account

  • The basics: Account is set up and owned by employer, there are no eligibility requirements, and no fees.
  • Plan availability: Account is offered with both traditional health insurance plans (Health Maintenance Organization (HMOs), Point of Service (POSs), Exclusive Provider Organization (EPOs) plans) and high-deductible health insurance plans (Preferred Provider Organization plans (PPOs)).
  • How it’s funded: Contributions are always deducted pre-tax from your paycheck. Distributions (when you pay for stuff) are tax free.
  • What’s covered: Can be used to pay for health insurance expenses such as co-pays, deductible, coinsurance, and prescription drugs, as well as over-the-counter (OTC) medical necessities such as Band-Aids and medication (with a prescription – yes, your doctor should write you a prescription for OTC medication if you ask – does not include Band-Aids). You should check your plan, but most of them cover the things the IRS considers tax deductible
  • Funds availability: The entire annual amount is available on day one, but your employer may impose a penalty if you use funds for non-medical items.
  • Rollover: Before the Affordable Care Act (ACA or Obamacare), the employee had to use the whole amount every year. If you didn’t, the remainder went to your employer. Now the employee can roll over up to $500 if the insurance plan permits it, and any funds rolled over are added to the next year’s maximum.
  • Contribution: The IRS has not set the FSA maximum for 2018, but projections are that it will remain the same as 2017, $2600. Employers can contribute amounts that push the total past the maximum, and you can only change contribution amounts during open season or upon marital status change.
  • Portability: An FSA will disappear with a job change unless you are eligible through COBRA (a limited and expensive continuation of a previous employer’s health plan).

Health Savings Account

  • The basics: Account is offered by the insurance provider and owned by the employee. Some may have a small fee, which an employer usually pays, but you should read the fine print to be sure.
  • Plan Availability: Only offered with high deductible health plans. To qualify for an HAS in 2018, that means a deductible minimum of $1350 for a single person/$2700 for a family and a maximum out of pocket cost of $6,650 for a single person/$13,300 for a family. Additionally, to qualify for an HAS, a health insurance plan must not offer any coverage beyond preventive care before the person/family meets the deductible.
  • How it’s funded: Contributions are tax deductible or can be deducted before payroll taxes are applied to your paycheck. Any growth or withdrawal is tax free. Some people look to these accounts as a good investment. I invariably go through them in a matter of a few months thanks to consumable medical supplies and expensive medications.
  • Funds availability: You can only use funds that have accumulated by the time of need, and if you use the funds for non-medical items, those funds will be subject to previously waived taxes, as well as a 20% penalty.
  • Rollover: Whatever is left at the end of the calendar year rolls over and accumulates.
  • What’s Covered: Can be used to pay for health insurance expenses such as co-pays, deductible, coinsurance, and prescription drugs, as well as over-the-counter (OTC) medical necessities such as Band-Aids and medication (without a prescription). You should check your plan, but most of them cover the things the IRS considers tax deductible
  • Contribution: The maximum contribution is $3450 for an individual/$6900 for a family. Individuals 55 and over can increase those amounts by $1000 (same for families), and you can adjust the amount of the contribution during the year.
  • Portability: You are allowed to keep using HSA funds even after you are no longer eligible to contribute (if you switch to a plan that does not qualify as a high-deductible plan), and it can follow you from job to job.

For more information on these types of plans, see IRS Publication 969. And if you have more questions about insurance before or during open season, please contact me.

It’s Open Season!

(Shhh, I'm hunting wabbits. Well, health insurance plans, but still . . .)

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It’s October, the traditional kickoff of Open Season, a time when both employers and the government present health insurance plans for the following calendar year. The period given to make a choice is short, sometimes just a week or two in the private sector. The enrollment period for plans under the Affordable Care Act (ACA or Obamacare) this year is November 1, 2017 through December 15, 2017.

Despite the long enrollment period for ACA plans, be careful when procrastinating this year. In an effort to depress enrollment in ACA plans, the Trump Administration has instructed the Department of Health and Human Services to allow the Healthcare.gov website to nurse its weekly hangover on every Sunday of the period, except the last one, December 10th. The site will be shut down from 12 a.m. to 12 p.m. on those days. For those of you who don’t procrastinate, the site will also be unavailable on the first night of the period, November 1st.

These deadlines are important to remember. If you miss the deadline for either private or public enrollment, you can’t enroll in a health insurance plan unless you start a new job.

Public and private plans tend to mirror each other since the passage of the ACA. One of the biggest things they have in common is the type of plans offered. Two of the most common are the Health Maintenance Organization plans (HMOs) and Preferred Provider Organization plans (PPOs).

The main differences between the two options are coverage and cost. (Please note that the below description are generalizations. Your plan may differ in some important ways.)


Coverage: Each insurance company has a network of doctors, hospitals, therapists, and other providers. A patient chooses a primary care doctor who is in the network. That doctor directs the patient’s care, including how much (whether they see other doctors) and by whom (which other doctors they see). If the patient needs to see a specialist, the primary care doctor has to agree that they need to and they must see someone in the network.

Costs: The insurance companies negotiate a discounted rate with their network providers, kind of like buying in bulk. If the patient wants to see a provider outside the network, the entire cost comes out of the patient’s pocket. But premiums are generally lower and co-pays are minimal, set costs ($5, $10, $20). HMOs often do not have deductibles.


Coverage: The insurance company still has network providers, but they are larger. There is no referral necessary to see a specialist so the patient decides how much care they need and who to see. If the patient wants to see an out-of-network provider, a PPO covers the cost, at least partially.

Costs: PPOs still have negotiated rates with in-network providers, but premiums are higher. PPOs also have high deductibles and co-pays, which are a percentage of the cost of the appointment or drug. PPOs also have maximum out-of-pocket costs, which sounds good, but not when you realize that there are separate ones for in- and out-of-network costs, and may amount to several thousand dollars annually.

How to Decide

You and your family will have to consider carefully which plan is right for your needs.

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  • How strongly do you feel about choosing your providers? I am very picky about my providers and tend to research a provider before I go or ask for names from providers I already trust. I do not want to be told I can’t go to the best providers for me just because they are out of network, so I have always had a PPO. That does not mean that there aren’t good providers in an HMO’s network. It just means that there are fewer options.
  • What kind of plan fits into your budget? I have a pretty reasonable premium, but I have two deductibles, and could end up paying $10,000 out of pocket this year.
  • Are the doctors you see in your plan’s network and do you have the relationship you want with them? If it matters to you to stay with the providers you have, this may be an important factor.
  • How likely are you to need one or more specialists? Many types of non-MD specialists often fall outside of network coverage: psychologists/social workers, nutritionists, chiropractors, etc.

If you want to know more about health insurance policies, check out these posts: Insurance 101, What is Health Insurance?, How Do They Figure Out What Plans to Offer and How Much They Cost?, Getting to the Bottom of What's Actually Covered

If you have questions about HMOs and PPOs, please email through the blog. I will try to answer your questions in subsequent posts.

Conversations with a Retired Healthcare Executive (Who Just Happens to be My Father)

Chapter 2: How do they figure out what plans to offer and how much they cost?  

Health insurance plays an outsized role in our lives. But does anyone really know how it works? Or, for that matter, what it really says? In this series, I will be talking to my dad, a retired healthcare executive, about a variety of topics to get some clarity on private (employer-supplied) health insurance.

Jeremy Sachs spent 30 years working for a Fortune 500 insurance company. During much of that time, as House Counsel for the Employee Benefits Division, he advised corporate managers of the Division on a wide range of legal issues relating to the Company's group health insurance policies, including during the times when the Health Insurance Portability and Accountability Act (HIPAA) and the Americans with Disabilities Act (ADA) were passed and instituted.

This series does not apply to Medicare, Medicaid, Obamacare (The Affordable Care Act, or ACA), or individual health insurance, unless otherwise specified.

The Players

Insurance Company

  • Sales Rep/Marketer—liaison between the insurance Company and your employer
  • Underwriters – determine the risks involved for each policy
  • Actuaries – mathematicians who determine the cost of a policy

Your Employer

The Process

Negotiations for a new health insurance policy or an update to an existing policy are long and complicated

They start with your employer. The insurance company’s sales rep sits down with your employer’s Benefits Manager and negotiates what your employer wants included in the insurance policy: what level of risk the insurance company is willing to take; what the deductibles will be; the method will be for computing a provider’s “reasonable and customary (R&C) charges”; and, what percentage of those R&C charges the company wants to cover. (That’s when the policy says they will cover 80% of reasonable and customary charges after the deductible or 70% of psychological therapy visits.)

Once the insurance company knows what the employer wants in the policy, the representative collects certain types of information about your employer, including:

  • Type of work (office/manufacturing/labor/academic/government, etc.)
  • Number of employees
  • Type of employees and percentages (skilled, management, executive, etc.)
  • Employee retention (In the insurance industry, employees who stay at their jobs longer may suggest a more stable lifestyle – that is, employees who keep a job for only a short time, and then move on are considered higher risk.)
  • Claims history from previous years. (A Group Policy issued to a brand-new company may cost more, since the Insurer will have to guess how high the first yearly payout of claims will be.
  • Company financial stability

And about you. Since it’s illegal to ask specific employee health questions, the insurance company will ask questions about the members of the group:

  • Gender
  • Age
  • Race/Ethnicity
  • Percentage who have dependents.*
  • Other general demographic questions

* Dependents are important because their – both children and spouses – costs are calculated at a higher rate than that for the primary insured. This is because since employees come to work on a regular basis, they are assumed to be generally healthy. But no such assumption can be made for dependents. Spouses and kids, as a group, tend to have more or higher claims than employees. (The kids I know definitely get sick or injured more often than the adults, but I am not sure why the spouses do. Dad didn’t know, either.)

These and other factors are all thrown into equations when the insurance company calculates the cost of the individual benefits offered in the policy, and the premium for the policy overall.

Once the sales rep has collected all the information from the employer, they send it to the underwriters. Underwriters determine how risky it will be for the Insurer to cover the group.  Keeling over from a heart attack is more likely in a sedentary cube farm than on an active factory floor. But losing a finger is more likely on a factory floor than in a cube farm. Unless you’re using the copier wrong.

Or, if the Company is located, say, in Florida, the group may have a more employees with respiratory conditions than in, say, in the Colorado Rockies, where the air tends to be purer. 

The underwriters start with “standard rates”. They take the gathered information and use complicated algorithms to determine how much risk of a claim is likely for each type of coverage that the employer wants in the policy. They then assign higher degrees of risk for any elements of the group that don’t fit the algorithm.  Then they send their calculations to the actuaries.

The Actuaries are the mathematicians who figure out how much to charge. Actuarial tables are always being updated. As treatments and knowledge around a condition improve, probabilities of severe consequences are adjusted and sometimes costs go down. But there are also new conditions that can’t be treated that have to be factored in. They create their own algorithms around the Law of Probabilities -- that you will need X treatment, based on current national or local (industry) claim experience. They create rates to be charged to the group based on a series of calculations of the probability that employees and dependents, as a group, may at some point need all or most of the insurance for the conditions covered by the policy. Then they figure out the rates for your employer’s Group Policy. 

With the rates in hand, the sales rep for the Insurer finally presents the policy package to your Benefits Manager. The package includes rates, definitions, and descriptions of what will be covered. These are the sections that specifically explain the insurer’s LIMITATIONS on what’s covered and lists of the risks that it will not cover at all (EXCLUSIONS), as well as a whole host of administrative requirements and other explanatory material.          

A squeaky wheel can impact your insurance policy.

So, after two pages, why does all this matter? Because you’re not as powerless as you think.

There is a long negotiation involved once the initial figures are given. Both sides are worried about competition. Insurance companies don’t want to lose clients to another insurance company because of lower prices, and your company doesn’t want to lose good employees to a competitor with better benefits. 

And that doesn’t even touch on unionized industries. Unions will often negotiate on the cost to employee and breadth of coverage. Like better maternity coverage for a younger employee pool or better rehab coverage for an older employee pool.

So, if you have an opinion, tell your employer. Start with the Benefits Coordinator or someone in Human Resources for companies that aren’t big enough to have a Benefits Coordinator. We had issues a few years ago with the pharmacy provider my company was using, and after a few years, there were enough complaints that my employer switched providers. [CS1] 

It’s not a guarantee, but it never hurts to speak up.


Every policy has an incurred but not reported (IBNR) reserve for health insurance claims, commonly referred to as a ”tail.” The tail covers late claims submissions. Sometimes I just don’t have the time and energy to submit claims, especially the out of network ones, so I wait until I do. The tail, based on the size of the policy, covers those late filings. The length of this grace period, called the IBNR runoff, varies with the policy, but is often six to twelve months. So don’t give up on reimbursement if you’re a little late. Know your IBNR runoff period, and give yourself a break.