Effective Cost Containment Requires Targeting Drivers On Multiple Levels

So, what can we do to continue to expand health care coverage through health reform without breaking the U.S. bank?  In an article titled “A Systemic Approach to Containing Health Care Spending” published in the August 2 New England Journal of Medicine, 23 health policy experts convened by the Center for American Progress set out nine major strategies to effectively contain health care costs both for public and private payers.

These experts insist that to effectively contain health care costs, strategies must target drivers of both the level and growth of costs and the role of medical prices and quantity of services; and eliminate administrative costs that do not improve health status and outcomes. The United States spends nearly $360 billion a year on administrative costs, accounting for 14 percent of excessive health spending.

“Although these solutions are not intended to be exhaustive, they have the greatest probability of both being implemented and successfully controlling health costs,” the report noted, emphasizing that it would be most effective to implement as a package the following recommended solutions.

• Negotiate uniform payment rates to apply to all payers and providers in a state; install an independent council to enforce a global spending target with growth per person limited to the average growth in wages. States will publicly report measured of quality, access, and costs with bonuses to be paid to high performing providers and payment rates adjusted for quality.

• Use payment alternatives to fee-for-service with fixed bundled payments for all the services and care a patient needs, including related rehabilitation and follow-up care for 90 days after discharge. Begin implementation as soon as possible using the bundles for 37 cardiac (heart) and orthopedic procedures used in the Medicare Acute Care Episode program.

• Implement competitive bidding for all medical equipment and devices, laboratory tests, radiological diagnostic services, beginning with Medicare and health insurance exchanges negotiating for private payers and state employee plans.

• Health insurance exchanges should offer tiered products based on high quality and low cost providers tied to reduced cost-share for insureds who use the high quality providers.

• Simplify administrative systems by electronic exchange of eligibility and claims information; use a single standard physician credentialing system; electronically provide monthly explanation of benefits statements; implement electronic health records integrating clinical (test orders, for example) and administrative tasks (billing, prior authorization, and payments).

• Require full transparency in medical provider pricing, including out-of-pocket costs, quality of care, and patient volume; prohibit “gag clauses” (which forbid contracted providers from disclosing to patients the discounts negotiated with insurers) on price information. Have state insurance department and health insurance exchanges collect, audit, and publicly report pricing and claims data.

• Expand use of non-physician providers such as advance practice nurses or nurse practitioners.

• Expand to private sector payers the Medicare ban on physician self-referral to facilities in which they or their families have a financial interest.

• Reduce costs of defensive medicine by providing a “safe harbor” for providers who use qualified health information technology and evidence-based clinical practice guidelines.

In conclusion, the NEJM article states, “These are the types of large-scale solutions that are necessary to contain health costs. Although many in the health industry perceive that it is not in their interest to contain national health spending, it is a fact that what cannot continue will not continue….Americans therefore face a choice. Payers could simply shift costs to individuals. As those costs become more and more unaffordable, people would severely restrict their consumption of health care and might forgo necessary care.

“We present alternative strategies to contain national health spending that allow Americans to access necessary care. Our approach addresses the system as a whole, not just Medicare and Medicaid. It is the path to rising wages, a sustainable federal budget, and the health system that all Americans deserve.”

New Standardized Identifiers For Health Care Providers Will Save Time, Money

Federal government efforts to reduce unnnecessary spending on health care administration continue with the backing of the Patient Protection and Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act (HIPAA).


Most recently, the Centers for Medicare and Medicaid Services (CMS) announced a final rule expected to save time and money for physicians and other health care providers by establishing a unique health plan identifier (HPID) and a data element that will serve as an “other entity” identifier (OEID) for entities that are not health plans, health care providers, or individuals, but that need to be identified in standard transactions. The rule also specifies the circumstances under which an organization-covered health care provider, such as a hospital, must require certain non-covered individual health care providers who are prescribers to obtain and disclose a National Provider Identifier (NPI). The final rule is scheduled to be published in the September 5 Federal Register.

The adoption of the HPID implements an administrative simplification provision of the ACA, and one of a series of changes required to cut red tape in the health care system. The measure is projected to save up to $6 billion over ten years. Currently, when a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format. As a result, health care providers run into a number of time-consuming problems, such as misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility. The final rule will simplify these processes.

Future administrative simplification rules enacting HIPAA will address adoption of:

• a standard for claims attachments;

• operating rules for claims attachments; and

• requirements for certification of health plans’ compliance with all HIPAA standards and operating rules.

“These new standards are a part of our efforts to help providers and health plans spend less time filling out paperwork and more time seeing their patients,” said Health and Human Services Secretary Kathleen Sebelius.

The rule also makes final a one-year proposed delay—from Oct. 1, 2013, to Oct. 1, 2014—in the compliance date for use of new codes that classify diseases and health problems. These code sets, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10) will include codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes.

This rule is the fourth administrative simplification regulation issued by HHS under the ACA, including the following with anticipated savings over ten years:

• On July 8, 2011—Operating rules for two electronic health care transactions to make it easier for health care providers to determine whether a patient is eligible for coverage and the status of a health care claim submitted to a health. Savings from this measure could be up to $12 billion.

• On Jan. 10, 2012—Standards for the health care electronic funds transfers (EFT) and remittance advice transaction between health plans and health care. Savings could be up to $4.6 billion.

• On Aug. 10, 2012—An IFC that adopted operating rules for the health care EFT and electronic remittance advice transaction. Savings are anticipated to be up to $4.5 billion.

The regulation is effective November 5. Health plans, excluding small health plans, are required to obtain HPIDs two years after the effective date, in 2014. Small health plans are required to obtain HPIDs three years after the effective date, in 2015. All covered entities are required to use HPIDs where they identify health plans that have HPIDs in standard transactions four years after the effective date, in 2016.

Covered entities have 180 days from the final regulation’s effective date to comply with the additional NPI requirement.

10 Tips For Choosing the Perfect In-Home Health Care Agency

When caring for your aging parent or loved one becomes overwhelming and you need a break, or when extra help is needed with bathing, feeding, dressing, household duties or if caring for them yourself is just not possible anymore, selecting an in-home health care provider is a good alternative.

Proper screening is essential to ensure that the person you choose has, not only the skills to provide excellent care, but also the right personality for the job. Consider these tips and hints and you will find that hiring an in-home heath care provider does not have to be stressful.

1. Evaluate Your Loved One's Needs
While some older adults just need assistance with basic living skills, others have additional health care needs that require a special skill set. Therefore, it is necessary to make a list of all of the duties that an in-home health care professional will need to provide so you can narrow down the list of candidates early on. If you are hiring through an agency, give them as much information from the start so they can match you up with someone who possesses all of knowledge and capabilities to give the best care possible to your loved one.
If your home health care worker will be assisting with bathing or dressing, it is important to discuss this with your loved one to make sure that they are comfortable with the gender of the companion. Women or men may become embarrassed when opposite gendered health care workers assist them with personal care and this may cause bath time to become stressful.

2. Speak With Local Experts
Before you go to the yellow pages or check out the classifieds for home heath aids, speak with neighbors, doctors, and elder care providers locally who can give you some recommendations and advice. Find out where other families have found in-home help and have them tell you about their experience. An administrator at a local nursing home may also have some suggestions for you on where to locate the best care giver. Support groups are a wealth of information, as well.

3. Create a Job Description
When you are ready to begin speaking with applicants and conducting interviews, start by writing a job description. The job duties can serve as talking points for your interview and also give the applicants a clear picture of what will be required of them.

4. Prepare Interview Questions
If you are not experienced at conducting formal interviews, you will benefit greatly by having a prepared list of questions. It will help you stay in control of the interview, not miss any key points, and make the best use of your time. Write it all down.

5. Outline an Employment Contract
Even if the person you select comes highly recommended and you and your family really hit it off with them, make sure to remain professional. This includes having them sign a contract that outlines your expectations, their duties, as well as boundaries. You can then refer back to the contract should a situation arise in the future. Often Home Health Agencies prepare the contracts themselves. Be sure to read them carefully and add anything that you wish to be included.

6. Personally Screen Candidates
Since the person you hire will be spending time alone with your parent or loved one, it is essential that you approve them yourself. Having an agency just send someone over is not acceptable in this situation. Even if they can paint a picture of a candidate's qualifications, because the job of health care provider is so intimate, personality is equally as important. If your loved one is able to participate in the interview, that is ideal. Regardless, they should spend some time together to make sure that they click.

7. Conduct a Background Check
Do not trust your intuition. When you think that you have found the person you want to hire, do conduct a background check to make sure that the person you hire does not have a questionable past.

8. Check References
Even if this is their first job in the field of health care, every applicant should be able to provide references. Ideally, these should come from past employers. Otherwise, professors, internship supervisors, and personal references can also be used.

9. Protect Your Home and Family
Since the health care provider you hire will most likely have free access to your home, possessions, and family members, find out if they are bonded. It they are not bonded themselves, find out if the agency that you hired them from is. Remember not to leave credit cards, checkbooks and personal papers in unsecured areas.

10. Stay Involved
Your job is not over once the contract is signed and employment has begun. The more of a presence you have in your loved one's life the better. Even if you can not be there in person, scheduling telephone meetings can let the health care provider know that you are involved and on top of things. Ask for progress reports and find out if there are any difficulties. Since the health care provider is around your loved one the most, they can give you the best information about their physical health as well as their state of mind.

One way to stay involved is to use a caregiver's organizer (which we just happen to offer on our website). The Caregiver's Companion is an organizational tool that has sections for personal information, family history, medications and side effects, medical appointments, and home health care workers notes. I hate selling, but this IS a very good tool in my opinion.

Shelley Webb has been a registered nurse for almost 30 years, with experience in the fields of neonatal intensive care, dialysis, case management and elder care. When her father came to live with her in 2005, the advantages of her medical experience became clear. Due to his dementia and congestive heart failure, her father was not able to care for himself alone any longer and so she took over these duties.

Having experienced the helplessness, frustration, overwhelm and even loneliness that care giving for an aging parent brings, Shelley is well aware of the emotional and educational support that caregivers need and so she began The Intentional Caregiver web site. With its weekly newsletter, daily news updates and monthly audio interviews of experts in elder care and supporting services, Shelley strives to encourage and educate caregivers so that they can be empowered to provide the best possible care for themselves while caring for their aging loved one(s).

A Systemic Problem in Our Healthcare System

Those of you who are old enough to remember the Australian bush nurse Sister Kenny (1880-1952), will no doubt recall the brouhaha she caused within the medical establishment of her time. Elizabeth Kenny had devised a treatment for polio that was universally castigated by doctors of the day. In fact her methods proved time and again to be efficacious and became the forerunner for the practice of physical therapy as we know it today.

The reason Sister Kenny, and her struggles with the established order of medicine, is brought to mind is that licensed medical doctors all too often behave like members of a closed-shop union. In such an environment, no one is allowed to do work that is perceived as encroaching on their specialty, without consequent castigation and sanction. And, they vigorously lobby for laws to protect them from perceived interlopers.

In Sister Kenny's case, she struggled for years to get her therapeutic methods accepted, even in the face of observable success, and admiring testimonials from patients. The medical profession cast aspersions on her methods and her person, largely because she wasn't an accredited practitioner (only a nurse), and her methods contradicted generally accepted treatment standards.

In today's contentious health care environment, alternative treatments are greatly frowned upon, and their practitioners ridiculed. Ask licensed doctors what they think of acupuncture, chiropractic, aroma or muscle activation therapy, and they will almost always turn up their noses. In fact, they have convinced the insurance industry that these methods are nothing more than palliatives bordering on quackery. Thus, patients are channeled into much more expensive surgical and drug treatments that often times provide no relief.

This is not to say that there aren't quacks hovering around the practice of alternative medicine, just as there are quacks who are licensed to practice the approved variety. It is also not claimed that there alternative methods for all sicknesses or diseases. But it is also true that in most professions, wherever there is a buck to be made, a surfeit of willing hands will extend to accommodate. We see desperately sick people try all sorts of last gasp treatments, especially after traditional medicine has given up on them. And these alternative methods seldom work.

However, in the less well defined areas of pain management, due to a variety of causes, modern medicine has proven to be quite fallible. Countless thousands of people suffer through painful days of agony with only the promise of relief provided by dangerous drugs. Doctors prescribe many unproven medications because their pharmaceutical rep told them this was the cutting edge drug du jour for pain management. Big Pharma and the medical profession work hand and glove to push their latest (and expensive) drug on suffering patients. And since only licensed doctors can dispense them, this conduit is exploited by both parties. Why there might even be a financial incentive for the prescribing doctor. Heavens!

Because of the built-in aversion to examining or even testing alternative therapies, the healthcare system is saddled with more expensive, "accredited" treatments that push the insured patients in that direction.

Even though back surgery has been shown to be less than 50% effective, and much less costly alternative therapies have proven efficacious, they are ignored. Worse, just as in Sister Kenny's case, they are scoffed at by the establishment. Such are the ironic side-effects of our costly for-profit health care system.

As another example of padding the bottom line is a practice that is becoming more common. Doctors are increasingly insisting on patients coming in for an office visit just to renew a prescription. Admittedly for some drugs it is necessary to monitor side effects (another indication of how dangerous some of them are), but in many cases it is totally unnecessary. As cuts in Medicare go into effect (which will increase, rather than cut costs), doctors will seek more ways to supplement their income. Once a professional is used to a certain level of earnings (no matter the discipline), it's hard to accept less. Doctors are no exception.

So, the bottom line is that there just might be ways to improve both the costs of health care and the patients' welfare by researching and approving alternative therapies. Sadly, that's not even on the table for discussion.

Raff is an author who took early retirement from a career in the computer industry to pursue a writing career. He has two non-fiction books in print. Information about him and his work may be found at http://www.raffellis.com

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States Proceed With Health Insurance Exchanges

California, Connecticut, Hawaii, Iowa, Maryland, Nevada, New York, and Vermont have received new grants from the federal government to help support the establishment of Affordable Insurance Exchanges, provided by the Patient Protection and Affordable Care Act. Starting in 2014, consumers and small businesses will have access to high-quality, affordable health insurance through an Exchange—an online marketplace where consumers can choose a private health insurance plan that, it is hoped, will fit their health needs and, maybe, budgets.


According to the U.S. Department of Health and Human Services (HHS), Exchanges will level the health insurance playing field, so that small businesses will have a better choice of plans and insurers at a lower cost, the way larger employers do now. These competitive health insurance marketplaces will make purchasing health insurance easier and more understandable and offer consumers and small businesses increased competition and choice, HHS said.

In addition, small employers will be eligible to receive tax credits for coverage purchased for employees through the Exchange. And, consumers will be able to learn if they are eligible for tax credits and cost-sharing reductions, or other health care programs like the Children’s Health Insurance Program.

This latest round of awards will give states additional resources and flexibility to establish an Exchange. On August 23, California, Hawaii, Iowa, and New York were awarded Level One Exchange Establishment grants, which provide one year of funding to states that have begun the process of building their Exchange. Connecticut, Maryland, Nevada, and Vermont were awarded Level Two Establishment grants, which are provided to states that are further along in building their Exchange and offers funding over multiple years.

Previously, 49 states, the District of Columbia and four territories received grants to begin planning their Exchanges. With the new grants, 34 states and the District of Columbia also have received Establishment grants to begin building their Exchanges.

In June 2012, HHS announced an initiative to provide states with ten additional opportunities to apply for funding to establish a state-based Exchange, state Partnership Exchange, or to prepare state systems for a Federally-facilitated Exchange. States can apply for Exchange grants through the end of 2014, and may use funds during the initial start-up year. This schedule ensures that states have the support and time necessary to build an Exchange that best fits the needs of their residents.

Health insurance exchanges aiming for real-time eligibility determinations using Treasury, IRS data

Health insurance exchanges should be able to make real-time determinations of eligibility for various types of coverage using data from the Treasury Department and the IRS, officials from the U.S. Department of Health and Human Services (HHS) said at a recent regional forum on implementing the Patient Protection and Affordable Care Act (PPACA) in Washington, D.C.

The PPACA generally requires states to establish American Health Benefit Exchanges by January 1, 2014. If a state decides not to establish an exchange for its residents, HHS will operate a federally facilitated exchange (FFE). Qualified taxpayers will be able to purchase health insurance coverage through the exchanges. Some taxpayers may be eligible for the Code Sec. 36B premium assistance tax credit to help them obtain coverage. The Treasury and the IRS have issued guidance on the Code Sec. 36B tax credit (I.R.B. 2012-24).

HHS officials said that, through the exchanges, individuals will be able to learn if they are eligible for programs to make insurance more affordable, such as eligibility for the premium assistance tax credit, or health programs such as Medicaid and the Children’s Health Insurance Program (CHIP). HHS is aiming for real-time determinations of eligibility for coverage, the officials said.

Federal agencies are planning a "data services hub" to facilitate the exchange of information, the officials said. An inter-agency task force is currently meeting to develop the parameters of the hub. "There is an incredible amount of complex work going on," one official said.

HHS establishes safe harbor for adverse benefit notices of non-federal governmental plans

The Department of Health and Human Services (HHS) has established an enforcement safe harbor with respect to the content of the adverse benefit determinations and final internal adverse benefit determinations issued by non-federal governmental plans. Guidance issued on August 17 indicates that HHS will not enforce the requirement, under Public Health Service Act (PHSA) Sec. 2719, that non-federal governmental plans provide notice of the private right of action under ERISA.

Similarly, HHS will not enforce the requirement that non-federal governmental plans provide contact information for the EBSA or a state department of insurance. This safe harbor is applicable as long as such a plan provides contact information for member assistance provided by any third-party administrator or health insurance issuer that is hired by or contracts with the plan, and, if available, consumer assistance offered directly by the plan such as applicable member services, employee services, human relations or fiscal or personnel department, or consumer support services, if applicable.

Notice requirement. PHSA Sec. 2719 requires that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage have an effective internal claims and appeals process. PHSA Sec. 2719(a)(2)(A) requires that such plans and health insurance issuers in the group market provide an internal claims and appeals process that initially incorporates the procedures of 29 CFR 2560.503-1 (the Department of Labor claims procedure regulation) and update such procedures in accordance with any standards established by the Secretary of Labor for such plans and issuers.

The Department of Labor claims procedure regulation clarifies the manner and content of notification of benefit determinations, which include certain disclosures. Among these required disclosures is a statement of the claimant’s right, under ERISA Sec. 502(a), to bring a civil action following review of an adverse benefit determination. ERISA Sec. 502(a) permits a plan participant or beneficiary to bring a civil action, among other purposes, “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.”

In addition, the Departments of the Treasury, Labor, and HHS have provided model notices for adverse benefit determinations. The model notices outline information that must be provided to claimants, including contact information for EBSA or a state’s department of insurance, as well as contact information for a consumer assistance program established under PHSA Sec. 2793 if one is available in that state.

Private right of action not available. The private right of action under ERISA Sec. 502(a) is not available to participants or beneficiaries of non-federal governmental plans, and the EBSA does not provide services to these participants or beneficiaries. In some cases, state departments of insurance do not provide services to these participants or beneficiaries. However, PHSA Sec. 2722(a) requires that non-federal governmental plans comply with the requirements found in the Department of Labor’s claims procedure regulation and the rules implementing PHSA Sec. 2719, including providing information on the private right of action under ERISA Sec. 502(a), and the information contained in the model notices. HHS indicates that complying with these requirements would place non-federal governmental plans in the difficult position of providing inaccurate information to participants or beneficiaries.

Consumer assistance program. In states that do not have a consumer assistance program, non-federal governmental plans that seek to take advantage of this safe harbor must provide the contact information for HHS’ Health Insurance Assistance Team (HIAT). The contact information for HIAT is 888-393-2789.

Other requirements still apply. This guidance does not provide non-federal governmental plans with relief from any other requirements of the PHSA, including the requirement that they provide all other notices required by the Department of Labor claims procedure regulation. Furthermore, to the extent that a non-federal governmental plan purchases a fully-insured health insurance policy for its participants or beneficiaries, or to the extent that state departments of insurance provide services to these participants or beneficiaries, HHS expects that participants and beneficiaries will receive the required contact information for the state department of insurance (or any other applicable state department).

House committee spotlights IRS need to prepare for health reform law implementation

The House Committee on Oversight and Government Reform, chaired by Rep. Darrell Issa, R-Calif., held a hearing recently to examine the IRS’s implementation of the Patient Protection and Affordable Care Act (PPACA). Issa said the law "has raised serious concerns about big government intrusion into Americans’ private lives," including questions about the "privacy of personal information once held only by the IRS but now shared with state [health care] exchanges." Issa also raised questions about the ability of Americans to comply with the law’s requirements, such as a requirement to provide, within 30 days, notification to a government agency about "key information": changes in income, household composition, marriage status and insurance coverage.

IRS Commissioner Douglas H. Shulman testified that "important progress on implementation has been made." In response to questioning from Rep. Danny Davis, D-Ill., Shulman said that the IRS will not have access to private health care information and will only get "barebones information. The IRS’s role has been way overstated. The IRS won’t have access to health care information except for the fact of coverage." The information provided will include whether the taxpayer has coverage, how many months the taxpayer has had coverage, and the identity of the insurer, Shulman indicated.

Shulman said that 92 percent of the IRS’s budget request for PPACA implementation for fiscal year 2013 is for operations support, information technology and operations investments. Shulman denied reports that the IRS will be hiring 16,000 agents to verify health insurance coverage and to enforce the health care law. "Generally, revenue agents…would not work on resolving these types of issues. Typically, these issues are addressed and resolved through written correspondence," he said.

Communication, education needed. IRS National Taxpayer Advocate Nina Olson told the committee that "the IRS has made significant progress toward ACA implementation," but "there remain significant concerns." Olson said a top IRS priority should be "communication and outreach to the many Americans who will not interact with the IRS on health insurance for the first time. In particular, these taxpayers may need education on the method by which the premium assistance tax credit is advanced to insurers and later reconciled with their tax returns. Finally, channels must be open for taxpayer referrals where another agency [such as the Department of Health and Human Services] makes a determination that the IRS must execute, and vice versa."

Olson testified that "certain ACA provisions have tax consequences that require Americans to understand their role beyond traditional return-filing at year-end. In particular, taxpayers at certain income levels may qualify for a premium assistance tax credit advanced by the government to their insurer. If their income at year-end turns out to be more than anticipated, the credit may be less than the amount advanced, and the IRS may recover the excess as a tax. To avoid receiving an excess, taxpayers may need to update information if their income or other relevant circumstances change. In effect, the premium assistance tax credit requires not only an initial application and a year-end tax return but ongoing updates on major life changes throughout the year. Because this updating role will be new, education of taxpayers is necessary to avoid unexpected tax consequences."

Former IRS Commissioner Mark W. Everson, vice-chairman of alliantgroup, L.P., Houston, Tex., stated that the need for the updating and timely provision of information will be new for taxpayers. Everson expressed concern that there will be "new players" handling tax-related information, such as exchanges, state governments and insurers, and that it will be challenging for these actors to protect against the improper disclosure of information.

Premium assistance tax credits questioned. Rep. Scott DesJarlais, R-Tenn., and other members of the committee questioned whether the IRS had exceeded its authority by providing for the premium assistance tax credit when taxpayers obtained affordable insurance through an exchange established by the federal government, as opposed to state governments. Shulman defended the IRS regulatory process and the Service’s reliance on career attorneys to draft proper regulations. The committee also heard from Michael Cannon, director of health policy studies, Cato Institute, Washington, D.C., who testified that premium assistance tax credits are not available through federal exchanges, and Prof. Timothy Jost, Washington and Lee University, Lexington, Va., who disagreed with Cannon.

GAO: estimates on post-ACA decline in employer-provided coverage vary

Researchers believe that certain provisions of the Patient Protection and Affordable Care Act (ACA) could affect employers’ future willingness to offer coverage, according to a new report from the Government Accountability Office (GAO), but as yet little consensus exists as to what the future holds for employer-provided coverage.

As noted in the report, Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage (GAO-12-768), ACA provisions that could affect employer-sponsored coverage include the individual mandate, the establishment of health insurance exchanges, group market reforms, and the “Cadillac” tax.

Tasked with a review of the "research" on this topic, the GAO examined two types of data. First, it reviewed five microsimulation model studies (those which estimate the combined effects of multiple ACA provisions, based on multiple data sets and assumptions) Second, it consulted 19 employer surveys published between Jan. 1, 2009, and March 30, 2012. In both instances, GAO examined (1) estimates of the effect of the ACA on the extent of employer-sponsored coverage; (2) factors that may contribute to the variation in estimates; and (3) how estimates of coverage vary by the types of employers and employees that may be affected, as well as other changes employers may be considering to the health benefits they offer.


Microsimulation models. The GAO found that the microsimulation model studies generally predicted little change in prevalence of employer-sponsored coverage in the near term. The five microsimulation study estimates ranged from a net decrease of 2.5 percent to a net increase of 2.7 percent in the total number of individuals with employer-sponsored coverage within the first two years of implementation of key ACA provisions, affecting up to about 4 million individuals. Two of these studies also indicated that the majority of individuals losing employer-sponsored coverage would transition to other sources of coverage, the GAO noted.

Employer surveys. Among the 19 employer surveys examined, 16 reported estimates of employers dropping coverage for all employee types. Among these 16, 11 indicated that 10 percent or fewer employers were likely to drop coverage in the near term, but estimates ranged from 2 to 20 percent. Most surveys were of employers currently offering coverage and therefore did not also address whether other employers may begin to offer coverage in response to the ACA; however, the three that did found that between 1 percent and 28 percent would begin offering coverage as a result of the ACA.

Some of the 19 employer surveys indicated that the ACA may have a larger effect on small employers and certain populations and may prompt some employers to change benefit designs, according to the GAO. For example, four surveys found that smaller employers were more likely than other employers to stop offering health coverage in response to the ACA, and five found that employers in general were more likely to drop coverage for retirees than for all employees. Nine surveys also indicated that employers are considering key changes to benefit design, some of which may result in greater employee cost for health coverage.

Mercer: ACA challenges acute for firms with part-time, low-wage workers

Companies with the greatest number of part-time and low-paid employees will face the greatest challenges from the reforms provided in the Affordable Care Act, a new Mercer survey has determined. Although 60 percent of the 1,203 employers Mercer surveyed expected some increase in cost as a result of the key ACA provisions effective in 2014, nearly half (46 percent) of retail and hospitality industry firms and two-fifths (40 percent) of health care industry employers anticipated cost increases of at least 3 percent. These industries have large part-time employee populations. Only 31 percent of service industry employers expected such an increase.

"With health benefit cost already rising at twice the rate of general inflation, an additional increase of 3 percent or more will be very tough for employers to absorb," said Sharon Cunninghis, leader of Mercer’s U.S. Employee Health & Benefits business.


Also, in companies where pay is low, employees who are eligible for coverage are more likely to opt out of enrolling, Mercer noted. For example, among large wholesale/retail and health care employers, opt-out rates average 19 percent and 18 percent, respectively, compared to just 8 percent among transportation, communication, and utility companies, where pay is higher. Once the individual mandate requiring all individuals who can afford coverage to obtain it (or pay a penalty) goes into effect, employers with high opt-out rates could experience a significant increase in enrollment.

Beginning in 2014, employers with at least 50 full-time employees working at least 30 hours weekly must extend health care coverage to these employees or pay a penalty. One-fourth of the respondents to Mercer’s survey said they will have to act to avoid penalties—ranging from 16 percent of financial services employers to 46 percent of retail and hospitality industry employers. Firms with low populations of part-time employees likely will make those employees eligible for the full-time employee plans or add new, low-cost plans (68 percent). However, employers with large part-time employee populations that do not currently offer coverage to these workers are more inclined to change their workforce strategy so that fewer employees would be eligible (67 percent of these employers, compared with 41 percent of manufacturing industry firms).



Employers counting on the ACA-provided Medicaid expansion for some of their low-paid employees may be foiled by the Supreme court decision that allows states to opt out of this expansion. One-fifth of survey respondents, but half of companies with large part-time employee populations, have employees that could qualify for coverage under the Medicaid expansion.


"Because state Medicaid eligibility already varies greatly, it’s difficult to predict what states will do about expanding their programs to more individuals, and the impact of their decisions on employers," said Branch McNeal, leader of Mercer’s Government Consulting business.


Source: Press release, www.mercer.com.

ACA rebate: you could get a check

In an effort to boost the overall popularity of the Affordable Care Act, the White House is touting the August mailing of a projected $1 billion in rebates that are required by the medical loss ratio provisions of the ACA.

Under the MLR provisions in the ACA, health insurance companies are now required to spend at least 80 percent (85 percent for large group plans) of premiums directly on health care, as opposed to advertising, administrative costs and executive salaries. Companies not meeting this requirement were required to send rebates to customers by August 1.

A White House e-mail, sent from info@messages.whitehouse.gov and captioned "Did you get your check," states that "nearly 13 million Americans will receive more than $1 billion from insurance companies this summer."

Group plan participants: don't get your hopes up. "There may be many employees who are expecting to receive a rebate check in the near future, but will receive nothing in hand," Garrett Fenton, Miller & Chevalier Chartered, Washington, D.C., told CCH. With respect to group health insurance coverage, even where an employer receives a rebate check from its insurer, that does not necessarily mean the employer will pass through the rebate directly to its employees, Fenton observed. He added, “In the context of ERISA plans, Department of Labor guidance provides employers with some discretion as to how to use or dispose of their MLR rebates, as long as they ‘act prudently, solely in the interest of the plan participants and beneficiaries, and in accordance with the terms of the plan.’”


And, of course, if you do get a rebate, you have to consider potential tax consequences.


In April 2012, the IRS posted FAQs addressing the federal tax consequences of MLR rebates. The FAQs explain that rebates are generally taxable if the individual policyholder previously deducted them on 2011 Form 1040, either on Schedule A or on line 29 as a self-employed individual. Rebates are also taxable if previously pre-tax premium payments are refunded to an employee participating in a group health plan, whether in a check from the insurance company, in a check paid through the plan’s administrator, or in the form of a premium reduction for the current 2012 year. The MLR rebates in those cases are considered a return to the employee of part of untaxed compensation that is no longer being used to pay for health insurance. MLR rebates are not taxable in cases of 2012 premium reductions based on 2011 premiums that had been paid on an after-tax basis. In such cases, the MLR rebate is considered a purchase price adjustment that reduces the cost of the participant’s 2012 insurance premiums.

Due to health reform, open enrollment planning more complex for employers

With annual open enrollment for 2013 rapidly approaching for most employers, Mercer, a benefits consultant, has created a checklist to help employers with their open enrollment planning, a task made even more difficult by health reform. "Health care reform has made open enrollment planning even more complex and daunting for plan sponsors," says Rich VanThournout, Health & Benefits business leader, Mercer’s Outsourcing business. This checklist can help “organize and prioritize key initiatives” to make this open enrollment season a successful one for employers, participants, and their vendors, alike, suggests VanThournout.

"Best-in-class health benefit strategies place a very strong emphasis on flawless implementation and administration, especially during the critical open enrollment season," adds Stephen Kreuger, Partner, Mercer’s Health & Benefits business. “Even with the impact of health reform top of mind, Kreuger suggests, Mercer’s checklist brings into focus the broader array of issues and ideas that plan sponsors need to consider well in advance of engaging participants in their health programs.”

Checklist. For employers with health plans, Mercer recommends considering the following factors:

• Use open enrollment to reinforce the value of your health and benefits program—Employees clearly appreciate their employer-sponsored benefits; 79 percent of respondents say their benefits are one of the primary reasons they work where they do, and 91 percent say that getting health benefits through work is just as important as getting a salary. Open enrollment is also a great opportunity to promote the tools and educational materials that help employees make better enrollment decisions, Mercer suggests.
• Understand the implications and scenarios of health care reform—Even before the recent Supreme Court ruling on the federal health care reform law, more than one-third (36%) of employees expected employers to change health plan benefits due to health care reform, more than double the level reported one year earlier. It is important that employers work with consultants, administrators and other stakeholders now in order to finalize all the requirements to be in compliance and allow enough time to implement and communicate plan changes.
• Leverage online/electronic communications—90 percent of employees of Mercer’s health and benefits administration clients enrolled online during the 2012 open enrollment period. In light of the fact that employees are receptive to receiving information online, employers consider, too, the cost savings of e-delivery of open enrollment materials. Other electronic communications, such as personalized emails, micro-sites and text messages, also have proven to be both popular and effective at driving informed employee enrollment behaviors.
• Consider adding a wellness program - Employees are increasingly appreciative of, and engaged with, wellness programs. Of the 61 percent who report that their company offers such benefits, 30 percent say they take advantage of these benefits "a great deal"—a number that is up significantly from 23 percent in 2010. These programs provide effective forums to drive employee appreciation of, and adoption of, healthy behaviors, which improves both employee engagement and the bottom line, Mercer points out.
• Move ahead of the crowd—The vast majority of Mercer Outsourcing’s health and benefits administration clients have their open enrollment windows start and/or end between the last week of October and the first two weeks of November. Employers should consider, when offering their open enrollment windows, to allow ample time for critical post-enrollment deliverables such as ID cards and targeted communication and education, particularly as related to health care reform.

With many U.S. health plan sponsors currently developing their strategies and tactics for the roll-out of their 2013 health benefit programs, the Mercer checklist can help ensure an efficient and effective open enrollment season. The checklist is based on Mercer’s experience and on key findings from the 2011 Mercer Workplace Survey, an annual study of employees who participate in their employer’s company-sponsored health plan.

Employers look to expand onsite health centers services

A significant number of U.S. employers with onsite health centers are planning to expand the scope of services offered, as well as the audiences eligible to use the centers, in the next 12 months, according to a survey by benefits consultant, Towers Watson. This expansion is expected to occur as pressure continues to remains strong to keep workers healthy, productive and on the job.

The 2012 Onsite Health Center Survey looks at 74 large employers that have established or are planning to establish onsite health facilities. Services offered at onsite centers can include onsite coaching, immunizations, biometric screenings, physical therapy, pharmacy and other medical services. According to the survey, most companies (62 percent) establish or keep their centers open to gain improvements in employee productivity that come from eliminating visits to offsite medical providers. Other factors for establishing a center include cost reduction (57 percent) and improved access to care (46 percent).

What services are offered. According to Towers Watson, currently, a majority of onsite health centers offer biometric screenings (81 percent), wellness counseling (73 percent), urgent care and first-responder services (70 percent each), and primary care services (63 percent). However, many companies plan to add new capabilities in 2013. Most notably, 28 percent of employers plan to add telemedicine, up from 8 percent that currently offer the service. In addition, 8 percent plan to add primary care services (63 percent currently offer); 6 percent plan to add full onsite pharmacies (24 percent currently offer), and 6 percent plan to add physical therapy (up from 41 percent currently offer).

"Employers believe onsite health centers can effectively address the key needs of increasing productivity, controlling costs and improving employee health," said Greg Mansur, senior consultant at Towers Watson. "It's important to note that onsite health centers will not be a fit for all companies. However, many of those companies that have embraced them believe they can pay even greater dividends in the future. Specifically, these employers are planning to offer new services and expand the audiences that can use them."

Who can use the onsite centers? Currently, over one-third (36 percent) of employers with onsite health centers allow spouses and children of employees to use their centers. Within 12 months, those numbers are expected to jump, Towers Watson says. An additional 13 percent are planning to allow spouses to use the centers, and another 11 percent are planning to allow children. More employers are also planning to allow former employees on COBRA, as well as temporary and contract employees, to use their centers.

"Treating covered dependents can provide as much value to an organization as treating an employee," said Patti Friedman, senior consultant at Towers Watson. "In fact, when evaluating the expected costs and savings of implementing an onsite health center, more use tends to translate into higher returns."

Other findings. Although employers and employees alike view the onsite health centers positively, Towers Watson found that only 38 percent of employers believe their onsite health centers generate a positive return on investment (ROI), compared with 9 percent that do not. The remaining 53 percent either don't know or don't track the ROI. Those that measure use lost time as the most common factor to make their calculations (74 percent).

Further, more than three-quarters of respondents do not expect their centers' service offerings to change due to health care reform. However, 30 percent expect the use of their centers to increase due to the Patient Protection and Affordable Care Act (ACA), while 34 percent do not expect an increase, and 36 percent are unsure about the effect of the ACA on their onsite health centers.

Heart Health: Which Fats Are Good for the Heart?

Hardly a day goes by without the nutrient 'fat' making a headline or two. How come? Eating too much fat is now widely recognised and linked to heart-health. How do we know which fats are healthier and which ones to eat less of? Is all fat bad for us?

Eating too much fat can lead to obesity. Eating too little fat can under-nourish us. What is the right balance of fat? Firstly, fats are actually a nutrient that are included in one of the main food groups and are part of a balanced diet. But there are many different types of fats available and it can sometimes be confusing to know which ones to buy and which fats to eat less of.

Solid Fats, Liquid Fats

Have you noticed how chilled butter and most cheeses are solid, that you need a knife to cut them? Well what you are cutting through is basically a solid wall of fat. The same is true for ice-cream, you need a scoop to extract it from the tub as it too contains a high percentage of solid fat.

Solid fat is solid at room temperature and is also known as saturated fat. It includes: cream, cheese, full-fat milk, the skin of chicken, bacon rind, the white streaky bits in ham and meats and butter.

Cakes, biscuits and chocolate sweets are usually high in saturated fat content also. So any foods that are made with hard cheeses, full-fat milk and cream may also be high in saturated fat content.

Saturated fats are useful in small amounts and provide warmth and protection for some of our vital organs like the adrenal glands. But let's say that a person eats large doses of saturated fats and carbohydrates over long periods of time, with little or no exercising and spends most of their day sitting down, well then this person may start to increase their weight as unused fats and carbs will be stored.

Saturated fats have developed a bad name for themselves, as when they are eaten in large quantities they have become linked to contributing towards thickening arterial walls.

Heart-Healthy Fats

Some fats have become known as the so-called 'good fats.' These are known as the unsaturated fats or ones which are liquid at room temperature. This includes olive oil, sunflower oil, avocado oil, walnut oil, peanut oil and soya oil to name a few. Any oil that is basically a liquid at room temperature is considered to be one of the healthier oils. These are usually known as the vegetable oils and they are rich in so called fatty acids.

Unsaturated fats are linked to being heart-healthy. It is widely recognised that eating less saturated fatty acids helps to support cholesterol reduction and thus helps to support a healthy heart. Vegetable oils tend to be high in Omega 3 and Omega 6, both of which are considered to be heart-healthy fatty acids.

Read the Labels in Supermarkets!

If you want to find out the fat content of the food you buy contains, start by looking at the labels in supermarkets. Nearly all labels now have the fat content of the foods listed. So it is easy to see how much fat the food contains and now also most labels will say 'Low' or 'Reduced Fat.' So if you think you need to cut down on the amount of fat you eat, then check with the labels as this really can make a difference to how much you digest.

Essential fatty acids are vital for healthy metabolism but cannot be produced in the body, so it is essential that they are supplied through the diet. Essential fatty acids include Omega-3 which supports a healthy heart and blood vessels. Omega 3 and Omega 6 fatty acids are both essential fatty acids.

Health Tips for Women of all Ages

There are many health issues that women should be aware of and they should be taking preventative measures to avoid. Many of these issues are specifically woman-centered, such as ovarian, cervical, and endometrial cancers. However, women also make up more than half of Alzheimer's patients, approximately 3.4 million out of 5.4 million Americans living with this disease. Helping women to know the risks and symptoms of certain woman-specific diseases, as well as preventative and treatment options, is important.

The big cancers that can affect women are uterine cancers: cervical, ovarian, and endometrial. Breast cancer also primarily affects women, though there are cases of male patients diagnosed with breast cancer. These cancers, for the most part, can be prevented, but sometimes your family history is enough to cause the disease.

Cervical cancer can be caught early if you are regularly going to your gynecologist for a pap smear. You should also consider quitting smoking if you do smoke, or avoiding secondhand smoke if you do not. Cigarettes have been linked to the development of many cancers, and besides the obvious ones like lung and mouth cancer, they do also cause cervical cancer. You may want to consider also getting the HPV vaccine if you are under 27 years of age.

Ovarian cancer is one of the more frustrating diseases to diagnose because there are no effective screening tests and no one really knows what causes it. Taking Fenretidine, which is a synthetic form of Vitamin A, might help to protect women against ovarian cancer as well as breast cancer, but there are not enough scientific studies that prove this to be an absolute. Your best bet, sadly, is to have your ovaries surgically removed. This may not rule out your chances of getting ovarian cancer entirely, but it is the most commonly recommended solution for patients who are high risk because of their family history.

Endometrial cancer's cause is also unknown, and unfortunately, this is also the most common type of cancer within the uterine area. High levels of estrogen seem to be a factor in whether a woman develops this disease. Also, if you have diabetes, polycystic ovarian syndrome (PCOS), have never been pregnant, or are infertile, your risk factor increases. To help prevent endometrial cancer, you should try exercising, changing your diet to introduce soy-based foods, and if you still are able, getting pregnant and breastfeeding.

Alzheimer's disease is a sad and difficult disease to deal with. Imagine losing your memories of those you love. It can be upsetting to know there may be nothing you can do to prevent its onset; thankfully, there are a few things that may help. Regular exercise 5 times a week for at least 30 minutes can diminish your risk factor. You should also consider changing your diet to include heart-healthy foods such as salmon and tuna, and excluding red meat and fried foods. Try adding in a few cups of green or white tea as well. Getting a quality amount of sleep is beneficial in all cases, but most especially when attempting to prevent Alzheimer's. Work on reducing stress in all areas of your life, and stay as active as possible.

Medical Supplies and Medical Equipment

How do you know what to consider when purchasing medical equipment? There are different aspects to consider in selecting medical supplies and medical equipment. It is not an easy task because of the wide variety of products available. Choosing quality medical supplies and medical equipment should be given thought and attention as you may end up with inappropriate items. Supplies may be deemed inappropriate if they are incompatible with the existing equipment, or if accessories and spare parts are no longer available.

The term medical supplies refer to items that are replaced on a regular basis. It can be classified into three categories; disposables, expendables and reusable items. Disposables are single use items like syringes and needles while consumables are items that can be used within a short span of time like laboratory stains, cotton wools and tape. Reusable items, on the other hand, are items that can be utilized in a limited amount of time such as thermometers and catheters. Medical equipment in contrast consists of durable items that can last for several years and are considered to be capital equipment. Examples of medical equipment include examination tables, beds, microscopes, weighing scales, sterilizers, and bedpans. In purchasing medical supplies and equipment, it is best to label items to help set priorities. There are items that are vital to health services, as well as items that are considered beneficial but are not quite critical and lastly, things that are only used for minor issues. Placing medical supplies and medical equipment in these categories will help in focusing on which items to purchase, especially if there are limited funds.

Once you determine which items are vital and essential, the next thing to consider would be the appropriateness of the items. For instance, equipment should not be replaced just because there are newer models available in the market. Some items are too technically complicated so it is best to consult with a member of the facility who is familiar with using the apparatus. A spare or replacement part, on the other hand, should be compatible with the existing equipment. Another thing to take into consideration is quality. If the item is expected to be used frequently for a long period, then it should be considered an investment and it is advised to purchase one of exceptionally high quality. Ask the manufacturer about the maintenance information and life span expectancy of medical equipments before purchase. Check the labels and packaging of any item for storage instructions and expiration dates for medical supplies.

It is also necessary to scout high-quality manufacturers. Only buy supplies and equipment from licensed, reliable and reputable sources. It is best to ask the supplier for their safety standards and performance warranties before completing any purchase. As a tip, it is more cost-effective to purchase new equipment rather than used, as used equipment has a much more limited life span. Apart from the manufacturer, the facility should also be checked to make sure that it has the utilities required to use the item. Also, inquire if the staff has the knowledge to manage, clean and maintain the medical supplies and medical equipment. Consult the training and service manuals if necessary.

Cristia Medical Supply Store offer cheap Medical Supplies and Medical Equipment.

Benefits of Natural Health Products

These days, more and more people are opting for natural health products over synthetic ones. People are now looking towards more natural means to improve their health and cure their sicknesses. Many experts have tried to prove the effectiveness of these natural health products, but although they have good results, some people are still skeptical about it. Some believe that synthetic medicines are still far more superior that these herbal alternatives. But come to think of it, people didn't have antibiotics and thousands of synthetic vitamins to keep them healthy centuries ago. They relied on natural health products to keep their bodies healthy.

Before discussing the benefits one can get from taking natural health products, let us first take a closer look on synthetic medicines and how they work. Synthetic medicines commonly contain a mixture of different chemicals. The best thing about these drugs is that they work fast and you can see the effects right away. However, since they are made up of lots of chemicals, synthetic medicines can leave harmful side effects on your body which could turn into something serious in the long term. Another downside is that regular use of these medicines could make the body dependent on it instead of its own natural defense. So as an effect, you end up buying these medicines for life which could be quite expensive.

Synthetic drugs are not the only form of medication available to cure diseases. Yes, there are natural alternatives available which work equally well. It is indeed possible to cure diseases without involving side effects. Natural health products are all about improving your immune system so that it can defend yourself from infections and other diseases. What's good about natural products is that they're all natural and made from natural herbs. It does not contain any synthetic chemicals so you don't have to worry about side effects and adverse reactions. Natural health products can help treat different kinds of diseases. It can help treat obesity, acne, diabetes, hypertension, stress, and many more. What's also good about these products is that they help treat the problem right at the source to avoid it from coming back. Some synthetic medicines only treat the symptoms but not the actual source of the problem.

Regular intake of natural supplements and products along with proper diet and a healthy lifestyle, could help you achieve optimum health. Natural medications may not be as fast acting unlike their synthetic counterparts but they're 100 percent safe and very effective. Your body deserves only the best so perhaps you may want to treat your health problems the natural way starting today.

Go natural today for your healthier future. Jem's Natural Living offers a wide assortment of eco friendly home products, organic baby products and natural health products.

Foods Not to Eat on a Healthy Diet

There are certain foods that, no matter how much we love them, we should avoid eating. At least for the most part!

Foods that cause inflammation:

    cheddar cheeses
    fast food
    fat free salad dressings (most contain sugar)
    french fries
    fruit juice cocktails (high in sugar)
    ice cream

    oils - vegetable, corn and canola
    pasta
    processed foods
    snack foods
    soft drinks, caffeinated and alcoholic beverages
    sugar, in any form
    white bread

Foods that contain trans-fatty acids:

    anything with partially hydrogenated oil
    artificial cheese
    chips - potato, corn/tortilla
    cinnamon rolls, doughnuts, pie crust, pastries
    commercial baked goods
    crackers
    deep fat fried foods
    margarine and shortening
    prepared mixes - cake, muffins etc.

Foods that are genetically modified such as:

    Canola Oil
    Corn
    Cottonseed Oil
    Soy

Also watch out for common "diet" foods that may actually sabotage your weight loss efforts:

Cereal. Check your labels to be sure your cereal contains whole grains and avoid cereals that are high in sugar.

Diet frozen dinners. Sure they're convenient but unfortunately most of these are very high in sodium.

Ground turkey. I have to admit that I've always believed that ground turkey is better as far as a healthy diet goes than ground beef. But it turns out when you compare 90% lean beef to 90% ground turkey the ground turkey actually has more calories and total fat than the ground beef. Although you can find ground turkey that is 97% lean and most ground beef sold in stores is 80% rather than 90% lean. But if you personally prefer beef it's good to know!

No-fat/Low fat ice cream and frozen yogurt. Sadly these types of frozen treats can contain up to twice the amount of sugar as regular varieties.

Prepared tomato sauce. While tomato sauce (which is high in lycopene) is good for you, most store bought brands are also high in sugar.

Sugar free, artificially sweetened drinks and snacks. These have actually been shown to cause weight gain.

Veggie chips. They are delicious but they are still fried and can contain as much fat as regular potato chips.

Yogurt. Presweetened yogurt is loaded with sugar and the sugar free varieties contain artificial sweeteners, which we know are also bad. I choose Greek yogurt and add fresh berries and nuts to it. I also use Greek yogurt in place of sour cream. They're similar in calories but Greek yogurt is much higher in protein.

Tips and Information on Natural Animal Health Care for Your Horses, Pets and Birds

Poor weight gain and lack of condition in our horses, pets and birds.

Since time began horses were naturally herd animals roaming and grazing in the wilds eating grasses and any in season herbs, weeds and flowers they naturally come across during the four seasons of the year.

Horses are now expected to eat large amounts of food once, twice or three times a day which is against their natural instinct. This is done simply because of our life styles but it greatly undermines the horse's natural eating habits and health.

Poor weight gain is a condition where the horse and pets fails to thrive in spite of being fed what may seem to be a normal diet.

To be able to provide the animal a balanced diet it is necessary to look at its original feeding habits. The bulk of their diet comprises of roughage, a variety of pasture grasses, herbs, flowers and weeds. Concentrates were eaten only when available as seed heads formed. Changes to diet were gradual and dictated by how far they moved per day and seasonal changes. Horses eat for most of the twenty four hour period during the day.

There are several reasons why your animals might be in poor condition despite the fact you might think it is eating a balanced diet, with simple tests from your veterinarian and the aid of a dentist you will be able to address this problem.

It is possible they could have;

A poor immune system.

An imbalance of vitamins and minerals in its diet.

An un-diagnosed low grade infection.

A slow digestive system that is not absorbing all of its nutrients.

An imbalance ratio of concentrates and roughage.

An incomplete metabolism of glucose and fluctuations in glucose levels.

A change to its feed regime.

Exposed to dust in stables, kennels and lofts, fungal spores carried in the air causing bronchial conditions and infections.

A nervous disorder like wind sucking and weaving or it could be highly strung.

A mouth infection or teeth problems.

These are just some of the problems your animals could be encountering.

Why maintaining our animals and birds body condition is so important.

Being underweight is unhealthy for anyone or anything and can reduce their athletic and reproductive performance. If an animal does not receive enough energy in its diet for a long period of time it will begin to lose body condition because its stored fat will be burned for energy.

When our they lose body condition and become thin any physical activity will be reduced.

Mares coming into breeding season also have difficulties and reduced conception rates in comparison to mares in good condition.

How can we address this problem?

As with any illness it must be addressed by a veterinary first followed by a diet high in recuperative antioxidants and plant substances that address the immune system.

A poor immune system can be maintained by using a good herbal supplement and with our Condition Enhancer that has been designed to aid and maintain good healthy condition for any living creature.

Vine Herbal Products makes no medicinal claims with this product it is designed to help maintain weight and condition for all animals and birds.

As with all of our products we recommend you seek veterinary advice before adding any supplement to your animal's diet.

Integrated Healthcare Systems

The world of healthcare is always changing.  When you think back to healthcare and health services back when our parents and grandparents were children and then compare things to healthcare today things are drastically different.  One thing that has changed and developed and also continues to change and develop as we speak is what is called the integrated healthcare systems.  Sometimes also referred to as multi-care providers or multi-care treatment, these systems intend on focusing on convenience for the client or patient and ease of working through the system.  Typically these systems cover a wide area of travel and are operated through multiple levels.  The systems also incorporate many different types of services including medical services and general health and wellness services as well.  The goal is the get you healthy and to keep you that way with this type of integrated system.

A system such as Manhattan Illinois healthcare has many different offices and services connected to it.  There is typically a large hospital that would be the main center and then many other clinics, offices, and even smaller hospitals that feed into and work off of or from the larger hospital.  Patients can visit a doctor in a medical center or office and expect to the same level of service if they visit a different doctor, hospital, or other provider that is within the same integrated healthcare systems.  There is also the benefit of having your medical records contained in the same system so that you don't have as much trouble trying to track down a get your medical records to all your different doctors.

Information is many times also maintained in the integrated healthcare systems information center so that if you visit Monee healthcare instead of another center then your information can be located because it is all consider the same provider.  In a way this is like an umbrella system that covers the patient.  There can be advantages for a patient and the goal of the integrated healthcare system is to make the experience better for both the patient and for the healthcare providers as well.

This way of providing care for patients is drastically different than how the doctors and nurses may have provided care in the past but one could say that it is an attempt on a large scale to make patients feel similar.  A doctor from Manteno healthcare is not likely to come to your home to provide care but the hope would be that because you are in this network of healthcare and provided quality and uniform care that you may feel somewhat like your father or grandfather felt with the doctor at their home.

A great website to check out if you are interested in an integrated healthcare system is Riverside Medical Center where you can get a good idea of how the system works and what they offer. You can visit the Manhattan Illinois healthcare [http://www.riversidehealthcare.org/locations/health-centers/health-center-info.html] center or the Monee healthcare [http://www.riversidehealthcare.org/locations/health-centers/health-center-info.html] location or the Manteno healthcare location to get an in person experience and some excellent healthcare as well.

Nutrition for Female Triathletes

Most women triathletes know intellectually that the right diet will enhance their training and produce far better results. In practice though, this is often harder to implement. When the chocolate bar, cream cakes and cola are calling our name it is easy to justify to ourselves that we exercise so much that it won't matter!

However success comes from the little things done well day after day after day.

In fact a good diet makes a huge difference! It will decrease overall stress levels, help maintain or achieve optimum racing weight and give us more energy to train before and after a hard day at work (even when we don't feel like it!).

Remember that exercising at high intensities causes damage in the cells of the body, high levels of lactic acid and stress in the actual cells. This is why we sometimes feel tired after exercise and experience muscle soreness. There is a high production of free radicals which cause cell damage. On top of this, pollution, stress and heat also damage cells.

Everyone has heard of the importance of anti oxidants. These clean up free radicals and reduce stress in the body. As a female triathlete you constantly need to replenish your level of antioxidants to combat the free radicals. This requires a proper diet packed with the right nutrients.

Whilst there are may books written on the triathlete's diet, they all come back to the same basis- eat natural food, loads of fruit and vegetables and plenty of water. Triathletes need more anti oxidants than the average sedentary person. Ditch processed foods, junk food, excessive coffee, alcohol and sugar.

As a rough guide I have listed some foods that are full of antioxidants to give you an idea of what you should be eating on a regular basis to help boost your levels and fight the free radicals in your system.

Pineapple, bananas, broccoli, chicken, fish, beans, peas, carrots, eggs, fish oils, oranges, nuts and seeds, peppers, cucumber and so on. There is so much choice you can never get bored. Use your imagination. Smoothies are another great way to get in a few servings of fruit in the one serving.

If you choose not to eat a majority of antioxidants, your training will suffer, you will take longer to recover from sessions and you will not be getting the results you deserve from all your training. So reach for the fruit and vegetables- organic where possible and you will feel the difference very quickly.

We hope you enjoyed our article. for more you can visit us at http://www.triathlonsuccess.co.uk/ and you can download our free book "The Top 5 Mistakes Most Triathletes Make And How To Avoid Them!"

Dropping heath coverage in favor of paying ACA penalty not a money saver

Ever wondered whether it’d be cheaper for a company to simply drop its health insurance coverage and pay any required fines under the Patient Protection and Affordable Care Act (ACA)? Many have speculated that it’d be more cost effective for employers to follow this route. Recent research from Truven Health Analytics disproves this notion, saying that “what is clear is that employers should not see the existence of an option not to cover their employees as a ‘slam dunk’ cost-saving measure.”

Employers opting to drop their health care plans in 2014 and pay the penalty imposed by the Patient Protection and Affordable Care Act (ACA) instead of maintaining coverage for their employees will not benefit economically in the short- or long-term, according to Truven Health Analytics. Beginning in 2014, employers with 50 or more full-time employees will be required to provide "minimum essential" health care coverage for their full-time employees or pay an annual penalty of $2,000 per employee (excluding the first 30 employees). The study, Modeling the Impact of "Pay or Play" Strategies on Employer Health Costs, analyzed four separate benefit design scenarios in which employers eliminate their group health coverage to determine how employers fare under this "pay or play" system.

Research findings. The report found the following:

• Employers will not experience immediate or long-term cost advantages if they choose to eliminate group health benefits.
• It will be more costly for employers to "make employees whole" when shifting their benefits to a Health Insurance Exchange than to continue existing group health plans.
• Dropping employer-provided coverage will result in a significant reduction in overall employee compensation, as the incremental costs of benefits will shift to the employees.

Conclusions. Truven Health Analytics offers several conclusions from its research. For instance, the researchers say, The potential penalties for dropping group plans, as well as the net gain most employees would need to receive in their compensation packages to make up for not receiving health benefits, should be enough to discourage most companies from discontinuing such services to their workers.”

However, the firm cautions that future research is needed to determine whether the patterns it current observes will persist after the Health Insurance Exchanges take effect in 2014. For example, “the economics of Pay or Play for midsized and large employers will be greatly dependent upon how the market for Exchange-based plans develops and whether Exchanges can offer plans that are as efficient or more efficient than existing group health plans. There may also be opportunities for an employer to selectively Pay or Play on a group-by-group basis.” Truven Health Analytics notes that it didn’t reflect this “more nuanced approach” in this current research.

“An employer’s cost calculations to Pay or Play are much more complex than simply balancing their current group health costs against the nominal penalties” under the law. “Not only is eliminating group health coverage not cost efficient, it may potentially have a large impact on an employer’s competitive market position for retaining and recruiting talent,” the researchers conclude.

Federal Court Dismisses Challenge to Affordable Care Act’s Contraception Requirement

U.S. District Court Judge Warren K. Urbom dismissed a case brought by attorneys general from Nebraska, Florida, Michigan, Ohio, Oklahoma, South Carolina and Texas that challenged the rule under the Patient Protection and Affordable Care Act (ACA) that requires health care plans to include contraception coverage, even for employees of certain religious institutions. The lawsuit, Nebraska v. HHS, which was joined by three employers associated with the Catholic Church and three employees of similar organizations, claimed that such a requirement violated the rights of non-exempt religious employers who oppose the use of contraception and threatened states’ budgetary stability.

The case was dismissed on July 17, 2012 on the grounds that the plaintiffs did not have standing to sue. The judge explained that the plaintiffs failed to show that they had suffered an injury that is concrete and not merely hypothetical. 

Because the ACA provides that employers who have “grandfather status” are exempt from the rule governing contraception, the decision first examined whether the plaintiff employers would even be required to comply with the rule. The judge did not have to delve farther than this to find that the plaintiff employers and employees did not have standing to sue.

Judge Urbom ruled that because two of the employers did not provide evidence that they were ineligible for grandfather status, they did not show that they were subject to the rule, and thus did not suffer a concrete injury. The third employer admitted that it would be grandfathered, but argued that under the rule it could only maintain its grandfather status if it did not change its current plan. However, the employer did not assert that it was contemplating changes that would threaten its exempt status. As such, this employer also failed to show that it would be required to comply with the rule. The individual plaintiffs’ standing to sue suffered from the same deficiencies. One plaintiff could not show that her plan was not grandfathered, and the other only asserted that her plan (which is grandfathered) might change at some indefinite time in the future.

Finally, the states’ claim failed to meet the standing requirements as well. In short, the state plaintiffs argued that, in an effort to avoid subsidizing contraception, religious employers would drop health insurance coverage for their employees. Those employees would then enroll in state Medicaid programs and cause the states to suffer budgetary strain. In addition, religious employers who continued to provide health coverage for employees would attempt to qualify for an exemption in the law that would result in the termination of charitable services to persons who do not share their religious views. Those underserved people would then rely on state resources. Judge Urbom ruled that this scenario merely recounts hypothetical injuries to the states based on speculation about how individuals, who are not before the court, may react to the rule. Such conjecture is not sufficient to establish standing.

Update on Health Insurance Exchanges: State Strategies, Progress Vary

Under the Patient Protection and Affordable Care Act (ACA), states are required to establish health insurance exchanges by 2014. In the wake of the Supreme Court’s decision affirming the law, some states are progressing toward making the exchanges a reality, while others are choosing not to do so. Under the law, states that do not set up such exchanges by January 2013 will have to pay to set up the exchange, but the federal government will take over the administrative operations.

Alaska:  Alaska Governor Sean Parnell announced on July 17th that the state will not set up a health insurance exchange, instead allowing the federal government to do so. The Governor explained that such action would eliminate uncertainty over implementation and federal approval and that using state funds to design and implement the program would have been too expensive.

Kentucky:  Governor Steve Beshear issued an executive order on July 17^th establishing a statewide health insurance exchange for Kentucky.

Michigan:  Although the state has $9.8 million in federal funds due to expire in November, it remains at an impasse in its effort to establish a health insurance exchange. The Michigan Senate approved legislation for the exchange, but is waiting for action by the House. As some Republican legislators have indicated that they wish to wait until after the election to act, the Republican House Speaker stated last week that he would not move forward on the issue until the House holds hearings. Although the Governor could establish the program by executive order, at this point he continues to encourage legislative leaders to make progress on creating an exchange. 

Minnesota: On July 16^th, the state announced that it signed a $41 million contract with Maximus, a Virginia-based firm, to design and maintain its state health insurance exchange through 2014.