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Readers And Tweeters: Doctors Chime In On Telemedicine Costs



Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Next Time Take Time To Consult Doctors On Telehealth

As a cardiologist and pediatrician at the University of Mississippi, I take issue with your article about telemedicine (“Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are Getting Billed,” April 27). Describing the care sessions as “phone chats,” as the headline on the companion NPR article did, substantially misrepresents what we do. Why did the article get published without the point of view of a single physician? The nature of this complaint boils down to this — I would never try to ask you to write journal articles for me, for free. We, in medicine, ask the same of you. If all phone consultations with physicians were free, we would never have time to see patients in the office. I urge you to write follow-up articles with a more balanced set of sources and realize how your article can now be used as ammunition to further constrain the way doctors practice. It is appropriate to remind readers to check their insurance coverage before they agree to a telephone consultation. It is not appropriate to then also call for free telephone or telehealth consultations.

― Dr. Frank Han, Jackson, Mississippi

— Dr. Yasmin Brahmbhatt, Philadelphia (responding to Dr. Mukta Baweja, New York City)

The article on telehealth was misleading and does the public a disservice by suggesting that physicians are approaching telehealth simply to increase their incomes.

Telehealth allows us physicians to see our patients and help them during a time of physical distancing. We are doing this not because it is “lucrative,” but to serve our communities, to do our jobs, and to take care of our patients while keeping them and our staff safe and healthy.

My practice revenue is down 85%. We have had a drastic reduction in patient visits, and I have already furloughed four of my 10 employees. These calls are far from lucrative, but, yes, they do help us keep the doors open.

Many other professionals charge for their time. After seeing patients throughout the day, we spend hours returning phone calls in the evening. These calls are not reimbursed; and frankly, they should be.

Phone calls and telehealth visits are not “chats.” They are medical consultations. You call your doctor for professional advice and guidance. You call your mother or your friends for a chat.

Dr. Rachel Schreiber, Rockville, Maryland

— Peter Borden, Boston

Jay Hancock’s story on telephone visits did not speak to physicians. Physicians should have been charging for telephone visits in the past (if the sessions met the criteria: initiated by the patient, not related to office visits or results from an office visit, or did not lead to an office visit), but reimbursement was only $14 per call. And many times the telephone calls did not meet billing criteria. However, with shelter-in-place laws and the pandemic, medical care has drastically changed. Patients don’t want to come to the office. They are thrilled to have telephone visits instead. Physicians are doing exponentially more of these telephone visits that meet billing criteria. Office visits have drastically decreased. The Centers for Medicare & Medicaid Services has changed reimbursement for telephone visits to be the same as for video visits, retroactive to March. Charging for telephone visits will help keep doctors’ offices financially afloat so medical care is available for patients in the future. This story is missing the perspective of physicians and also patients who are very happy with the telephone visits.

— Dr. Catherine Nelson, San Mateo, California

I am writing on behalf of the American Academy of Dermatology, which represents more than 20,000 dermatologists and their patients. All physicians, including dermatologists, are committed to providing the highest-quality patient care and have worked to safely offer care throughout the pandemic.

Your recent article correctly outlines how patients are utilizing telehealth to continue receiving care during the pandemic and describes discrepancies in how they’re being billed. While your article addresses these discrepancies in telehealth billing, it does not fully represent the significant challenges faced by patients, physicians and insurers as the health care system shifted abruptly in response to the pandemic.

Physicians are facing significant challenges including:

  • Lack of consistency. Many of the current telemedicine insurance policies are inconsistent and include differing reporting and delivery requirements, which creates a significant burden on practices and may delay the delivery of care.
  • Confusion surrounding reimbursement. Reimbursement levels and patient cost sharing for telemedicine visits vary across insurers. Many are following CMS and reimbursing in parity and eliminating patient responsibility while others are maintaining that patients must meet their standard obligations. This disparity has many practices collecting a deductible and refunding the patient’s deductible or copayment once the claim is processed appropriately.
  • Opportunity to work together. During this time of uncertainty, insurers and physicians are coming together to maintain continuity of care for patients. With any new process, challenges remain. Finding ways to harmonize the disparate requirements physicians are facing is paramount.

Our hope is that you will find this information helpful in providing a full picture of the medical profession’s intense obligation to keep Americans safe during the pandemic while administering quality care.

— Dr. Bruce H. Thiers, president of the American Academy of Dermatology, Rosemont, Illinois

— Liz Boehm, Cambridge, Massachusetts

— Rachel Kauser Nalebuff, Brooklyn, New York

Privy To Details About Community Spread

Regarding your series “Lost on the Frontline,” one critical topic was overlooked: fecal transmission and “contact tracing” of toilets. Though the Centers for Disease Control and Prevention says nothing about a fecal vector on its website, Chinese and U.S. researchers have been publishing their data on the coronavirus and feces for months. Toilet facilities for exclusive use by staff could be an overlooked vector that is tragically spreading this pathogen among health care workers.

An asymptomatic patient passes contaminated bowel movements for up to a week prior to feeling ill. Decades of research on uncovered flush toilets have shown their aerosol plume spreads bacterial and viral pathogens in a wide arc. Any location with a communal-use restroom has an inadvertent COVID-19 warehouse/distribution center (if it has been used by an infected person). The CDC can’t say, with any certainty, how long the coronavirus survives on various surfaces and whether it is infectious.

“Contact tracing” must consider which toilets were used by people who tested positive for COVID-19 during the preceding seven days. And then who used those facilities after the contaminated individuals. This flushed-toilet hypothesis, if valid, could explain cluster outbreaks in “contained” settings with designated staff toilets, e.g., ICUs, hospital admitting/triage departments, police precinct stations, corporate conference gatherings, restaurants, etc.

It might help to reflect on the CDC’s befuddlement at the Legionnaires’ disease outbreak in Philadelphia July 1976. Though the pathogen was a simple bacterium and the cohort of ill persons relatively contained and traceable, the agency’s epidemiologists and public health investigators were scratching their perplexed heads until a second outbreak in April 1977 enlightened them.

Getting beyond “respiratory droplets” may take even longer. This pandemic started as a gastrointestinal virus in the Wuhan market. The Coral Princess outbreak has recently been traced to an infected food worker. Until some bright epidemiologist redirects serious attention to fecal transmission and toilets, health care workers will continue to be at high risk of exposure to this deadly virus.

— Tom Heusel, retired registered nurse, Eugene, Oregon

— Dr. Christopher Chen, Miami

The Nuts And Bolts Of COVID Care

Your recent piece (“As Ventilators Become Crucial In Saving Lives, Repair Roadblocks Remain,” April 17) highlights an important and pressing issue.

As the COVID-19 pandemic puts unprecedented strain on our health care system, it is essential that we ensure medical devices are working safely and effectively. While third-party servicers play a crucial role in the post-market maintenance ecosystem, the fact is many operate in a regulatory “wild West.” In most cases, federal regulators do not even know about specific maintenance companies much less what their qualifications may or may not be. A 2018 Food and Drug Administration report estimated that the “total number of firms performing medical device servicing in the U.S. is between 16,520 and 20,830.” In other words, we do not even have a clear sense of the number of third-party servicers who work closely with medical equipment — a troubling reality, to say the least.

Non-manufacturer third-party servicers do not have to register with the FDA and are not held to the same quality, safety and regulatory requirements as original equipment manufacturer (OEM) servicers.

It is also important to remember that not all “right-to-repair” products are the same. If a repair goes awry with a mobile phone, at worst it may need to be replaced entirely. But the consequences of an improperly repaired medical device such as an MRI machine or ventilator can bring life-altering risks. That is why the FDA holds OEMs to specific quality and safety requirements and why we have advocated that, at a minimum, the agency should:

  • Know which third-party services are performing maintenance work
  • Assure all technicians are properly trained
  • Assure qualified parts are always used
  • Require detailed service records are maintained
  • Require applicable safety issues or events to be reported to the manufacturer in a timely manner.

It is unfortunate that some third-party servicers have chosen to use the COVID-19 pandemic to alarm the public and advance their business agenda. Instead of pushing for more unregulated servicing, they should register with the FDA, adopt quality management systems, and develop a mechanism for reporting adverse events.

Patrick Hope, executive director of the Medical Imaging and Technology Alliance

— Pat Kelly-Fischer, Denver

An Insurer Far From Interested In Bailout Money

Julie Appleby and Steven Findlay’s April 28 story, “Health Insurers Prosper As COVID-19 Deflates Demand For Elective Treatments,” implies that all health insurers are looking for a government bailout asking, “So why is the industry looking to Congress for help?” Not true. UnitedHealth Group, which includes UnitedHealthcare and Optum, will not request or accept any government relief money. Instead, we are focused on leveraging the full strength of our resources to support the health and safety of the people and communities we serve.

We are flexing our financial resources, clinical expertise and national reach in dozens of ways to help address society’s most critical needs. We’ve broadened health care access for patients by waiving cost sharing for COVID-19 testing and treatment, reduced prior authorizations, enabled and encouraged the use of free telehealth, offered early prescriptions refills, donated an initial $70 million to COVID-related causes, and delivered nearly $2 billion in accelerated payments to help care providers during a challenging financial time.

The 325,000 people of UnitedHealth Group are committed to doing as much as we can for the people and communities we are honored to serve during this difficult time.

― Kirsten Gorsuch, chief communications officer for UnitedHealthcare, Minnetonka, Minnesota

— Dr. Ed Mariano, Palo Alto, California

A Need To Expose Negligence?

Thank you for your exposé on assisted living facilities in the face of the COVID-19 pandemic (“COVID-19 Crisis Threatens Beleaguered Assisted Living Industry,” April 9). My comments are regarding what is missing from the article. Welltower Inc. is the largest player in the industry and it is not mentioned. Ventas, the second-largest player, is not mentioned either. The fact that neither the states nor the federal government took steps when they found how inferior the care was received no analysis.

And, finally, the federal law ― the REIT Investment Diversification and Empowerment Act — that empowers these Real Estate Investment Trusts (REITs) to be so careless with their residents is at the core of the maltreatment of the elderly. No one is addressing the RIDEA Act of 2007.

I have a lawsuit based on the alleged negligence of my mother in Sunrise of Stamford in Connecticut, and my legal team argued that although Welltower was “just a holding company,” under RIDEA it too had liability since it shared in the profits of the operating company. My point is that so much of this industry is ignored. I am fighting for someone to go deeper than the obvious.

― Ted Schachter, founder of Alzheimer’s Defense Fund, New York City

— Dr. C. Michael Gibson, Boston


Title: Readers And Tweeters: Doctors Chime In On Telemedicine Costs
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Published Date: Wed, 13 May 2020 09:00:04 +0000

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Retirement Planning

Ends-of-the-World Every Year Since 1970



There always has been and always will be a reason not to invest or not to stay invested. This is all the mainstream media reports to us. Below you will find a list of some of the worst global events each year since 1970. I have some commentary to follow.

1970: War: US troops invade Cambodia.
1971: Civil Unrest: Anti-war militants march on Washington.
1972: Political: Start of Watergate Scandal.
1973: Economic: OPEC raises oil prices in response to US involvement abroad.
1974: Political: Nixon resigns as President of the United States.
1975: Political: Multiple assassination attempts on President Ford.
1976: World: Ebola virus.
1977: Political: Government shutdowns.
1978: Market: U.S. Dollar plunges to record low against many European currencies.
1979: World: Iranian militants seize the U.S. embassy in Teheran and hold hostages.
1980: Economic: Inflation spiked to a high of 14.76%.
1981: Political: President Reagan assassination attempt.
1982: Economic: Recession continues in the U.S. with nationwide unemployment of 10.8%.
1983: Economic: Unemployment in the U.S. reaches 12 million.
1984: Economic: 70 U.S. banks fail during the year.
1985: World: Multiple airplane hijackings around the world.
1986: World: Chernobyl Nuclear Power Station explodes.
1987: Market: DOW drops by 22.6% on October 22.
1988: Environment: Awareness of global warming and the greenhouse effect grows.
1989: Environment: Exxon Valdez dumps 11 million gallons of crude oil into Prince William Sound.
1990: World: Persian Gulf War starts.
1991: World: Mass shooting in Killeen, TX.
1992: Human Rights: Los Angeles riots following the death of Rodney King.
1993: Terrorism: World Trade Center bombing.
1994: World: Mass genocide in Rwanda.
1995: Terrorism: Oklahoma City bombing.
1996: Terrorism: Olympic Park bombing.
1997: World: Bird flu.
1998: World: Multiple U.S. embassy bombings.
1999: World: Columbine shooting.
2000: Economic: Start of the Dotcom Market Crash.
2001: Terrorism: Terrorist Attacks in NYC, DC & PA.
2002: Economic: Nasdaq bottomed after a 76.81% drop.
2003: World: The U.S. invades Iraq.
2004: World: The U.S. launches an attack on Falluja.
2005: World: Hurricane Katrina
2006: World: Bird flu.
2007: Economic: Start of the Great Recession.
2008: Economic: Great Recession continues.
2009: Economic: S&P bottomed after a 56.8% drop.
2010: Market: Flash crash.
2011: Market: Occupy Wall Street and S&P downgrades U.S. Debt.
2012: Political: Fiscal cliff.
2013: Political: Taper tantrum.
2014: World: Ebola virus.
2015: World: Multiple mass shootings.
2016: Political: Divided U.S. Presidential election.
2017: World: North Korea testing nuclear weapons.
2018: Economic: U.S. & China trade war.
2019: Economic: Student loan debt reaches an all-time high of $1.4 trillion.
2020: World: COVID-19.

While many of these events were undoubtedly terrible (and there are certainly others not named here that were worse), most of these were broadcast as end-of-the-world events for the stock market. Despite that attention, it is worth noting that these were, for the most part, one-time events. In other words, most faded into the newspapers of history. We moved on.

Obviously, some caused monumental shifts in the way the world works. Just think about how much air travel continues to be impacted by the events of 9/11. But, outside of the resulting inconveniences (if we want to call safety protocols inconveniences) associated with air travel, flying is safer than ever before.

Take a look at just about any of the events and you will find there are many that people will hardly remember. My point here isn’t that these events are to be ignored or that they were easy to stomach at the time, but that they have become a distant memory.

I want to also make the point that we should expect these types of negative events. As investors, we know these types of crises, economic catastrophes, and global phenomena are going to happen.

But in almost all cases, here is what we can say in the next breath – this too shall pass.

Will there be legal, humanitarian, economic, or some other aid required as a result of these events? Almost certainly the answer is yes, but that doesn’t mean it they won’t eventually fade into history.

Lastly, what’s worth noting is how the market has performed over these last 50 years despite the continual advertisements of the world crashing down around us. On January 2, 1970, the Dow Jones stood at 809 and the S&P at 90 -> those are not typos. These same indexes have grown (not including dividends) to 26,387 and 3,232 respectively. Amazing, no?

Perhaps what gets overlooked more than anything else is what separates the above one-time negative events from the positive stories that go largely ignored over our lifetimes. And that is a story worth telling. See the companion post below:

Unheralded Positive Events Every Year Since 1970

Stay the Course,

Retirement Field Guide Mission:

“To help 10 million people make better retirement decisions.”

If you would like to join us in achieving our mission, I hope you will consider sharing our site if you have found it helpful in your own retirement planning.

This post is not advice. Please see additional disclaimers.

The post Ends-of-the-World Every Year Since 1970 appeared first on Retirement Field Guide.


By: Ashby Daniels, CFP®
Title: Ends-of-the-World Every Year Since 1970
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Published Date: Tue, 04 Aug 2020 13:26:19 +0000

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Wildfire prone property insurance bill in California due for hearing



The post Wildfire prone property insurance bill in California due for hearing appeared first on Live Insurance News.

The bill is expected to be heard in upcoming weeks as opposing sites prepare for major battle.

A new California bill, the outcomes of which will have a lot to say about coverage for wildfire prone property in the state, will soon be headed for hearing. The hearing is expected to be a heated one as strong opposing opinions have the opportunity to be voiced.

Opponents of this bill are calling it a direct attack on consumer protections in insurance.

That said, proponents of the bill claim it is the best method for making coverage available to wildfire prone property in California. The bill in question is Assembly Bill 2167. It was written by Assemblyperson Tom Daly (D-Anaheim). If it passes,it will create the Insurance Market Action Plan (IMAP) program. The IMAP program is meant to protect residential properties.

So far, AB 2167 has progressed quickly, when taking into consideration that a chunk of the legislature has been considerably restricted by pandemic crisis precautions. It was first presented in early June and backers have been saying that it was brought forward in good timing and that it has all the momentum it needs to be passed.

That said, AB 2167 has not been without opposition. In fact, it has faced considerable opposition, having been called an attack on Proposition 103, insurance consumer protection law. California Insurance Commissioner Ricardo Lara lobbed that argument at it, calling it an “insurance industry wish list, with nothing to help consumers,” and Consumer Watchdog, whose founder, Harvey Rosenfeld, was the original author of Proposition 103.

The insurance industry strongly supports the bill, saying it will help wildfire prone property coverage.

Insurance organizations such as the American Property Casualty Insurance Association and the Personal Insurance Federation both support AB 2167. The bill also has the support of the California Association of Counties (CSAC), as well as Fire Safe Councils of California, and the CalFIRE union.

The Consumer Federation of America, another watchdog organization, has predicted that if AB 2167 passes, it will cause 40 percent increases in insurance rates. On the other hand, insurance groups claim that the bill offers owners of wildfire prone property a greater opportunity for choice and competition among insurance companies based on coverage and premiums while avoiding the limitations and high costs associated with FAIR Plan coverage.

The post Wildfire prone property insurance bill in California due for hearing appeared first on Live Insurance News.


By: Marc
Title: Wildfire prone property insurance bill in California due for hearing
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Published Date: Fri, 14 Aug 2020 09:00:14 +0000

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Is this the last hurrah for bonds?



Recently, I have written quite a bit about the long-term return expectations for investing in bonds. See here, here, here and here.

Spoiler alert: I don’t think it’s good.

But long-term bonds this year have been quite an amazing story as the COVID pandemic has caused the Fed to take historically monumental actions. As a result, we’ve watched long-term Treasuries tear the roof off the market. For instance, a 20+ Year Treasury Bond ETF (name withheld for compliance purposes) is up more than 31% YTD as of July 31st.

That is insane!

But there is a good reason for this increase shown below.

The red circle shows a decrease in the 30-year Treasury rate of almost 40% over a span of six months. That’s practically unprecedented with only two periods (2008 and 1981-1982) having similar declines over such short periods.

But this begs the question: Is this the last hurrah for bonds as a driver of any meaningful return? Below is the 30-Year Treasury rate over the last 40+ years.

For what it’s worth, people have been forecasting the end of the bond bull market since 2012 (maybe even earlier) and yet it has continued despite those predictions. But at some point, the bond party will come to an end.

The Fed has been clear that they are going to keep rates stable until at least 2022 which means this may not change for a little while longer. Or in the near term, I could even see the high returns continuing if we experience pandemic economic shutdown round two.

But, I can’t see a world where this is the case for much longer than that – most importantly over the span of a 30-year retirement.

The official end of the bond bull market depends on a recovery from the pandemic economy as well as a few other factors causing rates to rise. But when they do, it seems likely to me that this may be the last great hurrah for bonds for quite some time.

The question is when to get off that train and that undoubtedly requires a personal answer.

Stay the Course,

Retirement Field Guide Mission:

“To help 10 million people make better retirement decisions.”

If you would like to join us in achieving our mission, I hope you will consider sharing our site if you have found it helpful in your own retirement planning.

This post is not advice. Please see additional disclaimers.

The post Is this the last hurrah for bonds? appeared first on Retirement Field Guide.


By: Ashby Daniels, CFP®
Title: Is this the last hurrah for bonds?
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Published Date: Wed, 12 Aug 2020 13:47:16 +0000

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