Norway: How many Kronas?

Summer is here!! Out of absolutely nowhere the sun is out, the nights are balmy and the mercury has jumped about ten degrees. I now have two superfluous hoodies in my backpack, which I'm pretty sure will be ditched the moment I confirm the UK has followed this summer trend. I'm writing this from a bus on my way from Oslo to Copenhagen after an amazing week in Norway, the third leg of my scandanavian Uni reunion tour.

Backpacking in Norway is a lot like dating a supermodel. It's spectacular, and beautiful and you love every minute but deep down you know you can't afford it.  Foolishly I decided to spend an entire wek here visiting my old teammate TC. Scandanavia in general hadn't been too bad up until this point. Sweden had been expensive, but only because I'd decided to go out drinking every night, Norway however took one look at my $500 budget for the week and just laughed. It doesn't help that the currency is the krona, which has the has a decimal place one spot to the right, meaning you're always spending in tens and hundreds, but the worst part is that our dollar only buys six kronas. The net effect of this is you go buy two beers and all of a sudden all of your money is gone.

However, just like with a supermodel, if you spend too much time worrying about how much you're spending while you're here, then you're missing the point. Norway is spectacular. I arrived on an overnight bus from Stockholm at 530am, then proceeded to get completely lost trying to find TC's place. I managed to lug my backpack around for 2 hours, being told the wrong directions by 3 different cabbies, before finally getting spot on directions from a blonde beauty going for her morning jog (there's a lesson in there somewhere I'm sure). TC wasn't actually living at his apartment yet, as he'd just bought it. So I had to wait another hour before he got there, meaning I had to wait even longer to get some real sleep on a cushioned surface. However when TC arrived I was presented with a beer and told to suit up as we were hitting the town after a champagne breakfast with his mates. I figured, what the hell, when in Rome, do what the drunken rich classy norwegians do. One of  his mates donated me a suit, which was very lucky as this would have been a new low for me in a life of chronically underdressing, rocking skate shoes, jeans and a wrinkled shirt in a posse of guys who looked like they were straight out of Mad Men.

I heard the phrase 'Norway's Independence day' thrown around a few times, but I'm pretty sure this was just a standard Thursday in Oslo. It was a crazy party. After breakfast champagne, beer and shots and a delicious spread of cheese and italian meats on bread rolls (they have this for breakfast all over Scandanavia, I'm moving here if I ever become a cardiologist!) we headed out onto the town where pretty much all of Oslo was out in traditional dress or suits, and with a beer in their hand.

Herr TC Valle and myself classier than we ever were at Lander



This photo is only to show the norwegian traditional dress.


I won't bore you with too many details of the day, partly because it was a lot of shameless spring break style shenanigans that shouldn't be mentioned in polite company, but mainly because by the end of the night my memory got a bit fuzzy. One thing I do remember was the graduating high school students and their party buses. Apparently Norwegians looked at the one week debauchery of schoolies in Aus, or spring break in the US, and thought it was a bit weak. Instead their high school leavers get their own bus which they ride around in, drinking, pulling pranks and generally causing chaos for A MONTH!! They then do their final exams a week after this! Christ I'm glad I didn't go to school here. I managed to miss pretty much all the iconic high school parties because I was playing tennis. Considering I got in trouble for staying late at a party two weeks before the HSC, I'm pretty sure my parents would've had me as the only student to miss all of Schoolies month.

And that's how you become the wealthiest per capita country in the world...

The next day, with both of us nursing hangovers, we headed for the fjords. TCs dad had let us borrow his BMW (as you do) and we were heading across the middle of the country to Stavangar. Most people thought we were crazy doing this, as you can drive faster by the south coast, or fly for almost the same cost and in 7 hours less time. Most people are missing out. The drive was one of the most amazing things I've ever done. There was everything, from rolling rivers, alpine roads through snow fields, ferry rides, and the most spectacular roads weaving alongside the fjords. It was also great fun as TC and I proved once again that planning is for suckers. We didn't really plan our way across and may have taken the slightly scenic route. By that I mean we had to double back at one point and then ended up on a route where we had to catch a ferry at midnight, a time we weren't 100% sure the ferry would be running at. If the ferry wasn't running we would have arrived around 4am. The end result of this was we got a ferry ride at sunset, free hot dogs (which in Norway are wraped in bacon!!) and chocolate buns from a servo restaurant we stopped into to ask about the ferry times, and we literaly drove straight onto the midnight ferry as we arrived, exactly as it docked.

Bacon AND crispy onion AND their own special hot dog sauce. What a country.

We managed to take a couple of hundred photos along the way, usually with TC yelling "tunnel" or "fjord" and demanding I take the photo. I also introduced TC to the jumping photo, which ended up dominating most of the rest of the photos for the trip. We ended up getting in at 1am to TCs friends Christian and June's place, who had beers and shrimp sandwiches waiting for us. Pretty tough day really.

We ended up going to two different fjord spots, one called the preachers pulpit, and another where there's a rock stuck between two cliffs (don't remember the name). In keeping with the theme of the trip we did pretty much no planning and just rocked up with a couple of bananas and half a bottle of water. Our hike sort of turned into a bear grylls episode from there. If he does an episode where the scenario is someone getting teleported from their desk at work onto the top of a snow covered cliff then I'm pretty sure TC will get paid royalties. We got told that it was a 30 minute to 1 hour hike, and that there may be a little snow on the wedged rock. Turns out there was 2 metres deep snow on half of the hike, the route took about 4 hrs total, and the wedged rock was completely inaccessible thanks to snow covering the track leading to it. However we trudged onwards, despite the fancy hiking gear wearing people looking at us doubtfully and trying to warn us not to go.  In the end it was so worth it, and the hike was really fun. One part had a hill about 200m high at an angle of like 35° which was covered in deep snow. It was a bastard to ascend, but the descent on the way back was awesome, and we did it in about 20 seconds. The view at the end of the hike was incredible, and naturally we took another couple of hundred jumping photos. We capped off the day with the champions league final, and a well earned beer, and then a whole bunch of ill advised ones.

Also, just as an aside, below there will be some photos of people near very high cliff faces possibly jumping or hanging over the edge of drops up to 800m high. Norway, with all of its wealth, has invested in see through safety rope systems, which are attached to each hiker. You wont see these in the photos because they're see through! Therefore if you happen to be the mother of anyone in the following photos, you'll have nothing to worry about and can just enjoy the lovely scenery.

The drive on the way up, when we began to realise it might not just be a light dusting of snow.

Saskwatch sighting

TC's 'hiking' shoes letting him down.

Knackered Valle

The next day we did the much easier (and not snowed in) hike to the preachers pulpit. I'll just let the photos talk for this place. 



That little speck is me.


We then did the long drive home and I've been spending the last few days just  hanging out in Oslo with TC and his family. I checked out a couple of cool things in the city. One was the park in town (forgot the name again) that has some very cool sculptures. I want to find out the story behind it because this guy would've been an interesting spouse. Although his angry kid statue is so perfect.

Thats a big knife. Seriously though, why do palaces require guards to stand there for hours on end. Surely one dude and a bunch of security cameras and a phone would do, like it does for security everywhere else.

The extremely lovely Mrs Valle and an empty dishy that had only minutes before contained a massive lasagne.

Alright America, we'll see your Washington monument and raise you some naked dudes.

Like I said, this guy had an interesting family life.

Baby Alan Jones

I also checked out their ski jump that overlooks the city. I've decided I now want to go watch this sport live!

Some Norwegian dude and his faithful poodle.

Anyway, it was an awesome week, and while not for backpackers, Norway is just brilliant and I can't recommend it highly enough. I've got to say a massive thanks to TC and his family and friends. They did so much for me it was insane, and I can't wait to return the favour someday in Aus.

So I guess that's everything for the moment. I've got 4 more hours on this bus and if current trends continue, that means 2 more run throughs of Adam Sandler's masterpiece 'Jack and Jill' which has been dubbed in  Norwegian with one guy voicing every single character...to think all that fine female impersonating could be undone by these uncultured nords! Philistines!
Will  probably write next from London after a whirlwind ride through  Copenhagen, Amsterdam and Paris.

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Who's Paying For Health Care?

America spent 17.3% of its gross domestic product on health care in 2009 (1). If you break that down on an individual level, we spend $7,129 per person each year on health care...more than any other country in the world (2). With 17 cents of every dollar Americans spent keeping our country healthy, it's no wonder the government is determined to reform the system. Despite the overwhelming attention health care is getting in the media, we know very little about where that money comes from or how it makes its way into the system (and rightfully so...the way we pay for health care is insanely complex, to say the least). This convoluted system is the unfortunate result of a series of programs that attempt to control spending layered on top of one another. What follows is a systematic attempt to peel away those layers, helping you become an informed health care consumer and an incontrovertible debater when discussing "Health Care Reform."

Who's paying the bill?

The "bill payers" fall into three distinct buckets: individuals paying out-of-pocket, private insurance companies, and the government. We can look at these payors in two different ways: 1) How much do they pay and 2) How many people do they pay for?

The majority of individuals in America are insured by private insurance companies via their employers, followed second by the government. These two sources of payment combined account for close to 80% of the funding for health care. The "Out-of-Pocket" payers fall into the uninsured as they have chosen to carry the risk of medical expense independently. When we look at the amount of money each of these groups spends on health care annually, the pie shifts dramatically.

The government currently pays for 46% of national health care expenditures. How is that possible? This will make much more sense when we examine each of the payors individually.

Understanding the Payors

Out-of-Pocket

A select portion of the population chooses to carry the risk of medical expenses themselves rather than buying into an insurance plan. This group tends to be younger and healthier than insured patients and, as such, accesses medical care much less frequently. Because this group has to pay for all incurred costs, they also tend to be much more discriminating in how they access the system. The result is that patients (now more appropriately termed "consumers") comparison shop for tests and elective procedures and wait longer before seeking medical attention. The payment method for this group is simple: the doctors and hospitals charge set fees for their services and the patient pays that amount directly to the doctor/hospital.

Private Insurance

This is where the whole system gets a lot more complicated. Private insurance is purchased either individually or is provided by employers (most people get it through their employer as we mentioned). When it comes to private insurance, there are two main types: Fee-for-Service insurers and Managed Care insurers. These two groups approach paying for care very differently.

Fee-for-Service:

This group makes it relatively simple (believe it or not). The employer or individual buys a health plan from a private insurance company with a defined set of benefits. This benefit package will also have what is called a deductible (an amount the patient/individual must pay for their health care services before their insurance pays anything). Once the deductible amount is met, the health plan pays the fees for services provided throughout the health care system. Often, they will pay a maximum fee for a service (say $100 for an x-ray). The plan will require the individual to pay a copayment (a sharing of the cost between the health plan and the individual). A typical industry standard is an 80/20 split of the payment, so in the case of the $100 x-ray, the health plan would pay $80 and the patient would pay $20...remember those annoying medical bills stating your insurance did not cover all the charges? This is where they come from. Another downside of this model is that health care providers are both financially incentivized and legally bound to perform more tests and procedures as they are paid additional fees for each of these or are held legally accountable for not ordering the tests when things go wrong (called "CYA or "Cover You're A**" medicine). If ordering more tests provided you with more legal protection and more compensation, wouldn't you order anything justifiable? Can we say misalignment of incentives?

Managed Care:

Now it gets crazy. Managed care insurers pay for care while also "managing" the care they pay for (very clever name, right). Managed care is defined as "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care prior to its provision" (2). Yep, insurers make medical decisions on your behalf (sound as scary to you as it does to us?). The original idea was driven by a desire by employers, insurance companies, and the public to control soaring health care costs. Doesn't seem to be working quite yet. Managed care groups either provide medical care directly or contract with a select group of health care providers. These insurers are further subdivided based on their own personal management styles. You may be familiar with many of these sub-types as you've had to choose between then when selecting your insurance.

Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO):This is the closet managed care gets to the Fee-for-Service model with many of the same characteristics as a Fee-for-Service plan like deductibles and copayments. PPO's & EPO's contract with a set list of providers (we're all familiar with these lists) with whom they have negotiated set (read discounted) fees for care. Yes, individual doctors have to charge less for their services if they want to see patients with these insurance plans. An EPO has a smaller and more strictly regulated list of physicians than a PPO but are otherwise the same. PPO's control costs by requiring preauthorization for many services and second opinions for major procedures. All of this aside, many consumers feel that they have the greatest amount of autonomy and flexibility with PPO's.

Health Management Organization (HMO): HMO's combine insurance with health care delivery. This model will not have deductibles but will have copayments. In an HMO, the organization hires doctors to provide care and either builds its own hospital or contracts for the services of a hospital within the community. In this model the doctor works for the insurance provider directly (aka a Staff Model HMO). Kaiser Permanente is an example of a very large HMO that we've heard mentioned frequently during the recent debates. Since the company paying the bill is also providing the care, HMO's heavily emphasize preventive medicine and primary care (enter the Kaiser "Thrive" campaign). The healthier you are, the more money the HMO saves. The HMO's emphasis on keeping patients healthy is commendable as this is the only model to do so, however, with complex, lifelong, or advanced diseases, they are incentivized to provide the minimum amount of care necessary to reduce costs. It is with these conditions that we hear the horror stories of insufficient care. This being said, physicians in HMO settings continue to practice medicine as they feel is needed to best care for their patients despite the incentives to reduce costs inherent in the system (recall that physicians are often salaried in HMO's and have no incentive to order more or less tests).

The Government

The U.S. Government pays for health care in a variety of ways depending on whom they are paying for. The government, through a number of different programs, provides insurance to individuals over 65 years of age, people of any age with permanent kidney failure, certain disabled people under 65, the military, military veterans, federal employees, children of low-income families, and, most interestingly, prisoners. It also has the same characteristics as a Fee-for-Service plan, with deductibles and copayments. As you would imagine, the majority of these populations are very expensive to cover medically. While the government only insures 28% of the American population, they are paying for 46% of all care provided. The populations covered by the government are amongst the sickest and most medically needy in America resulting in this discrepancy between number of individuals insured and cost of care.

The largest and most well-known government programs are Medicare and Medicaid. Let's take a look at these individually:

Medicare:

The Medicare program currently covers 42.5 million Americans. To qualify for Medicare you must meet one of the following criteria:

Over 65 years of age

Permanent kidney failure

Meet certain disability requirements

So you meet the criteria...what do you get? Medicare comes in 4 parts (Part A-D), some of which are free and some of which you have to pay for. You've probably heard of the various parts over the years thanks to CNN (remember the commotion about the Part D drug benefits during the Bush administration?) but we'll give you a quick refresher just in case.

Part A (Hospital Insurance): This part of Medicare is free and covers any inpatient and outpatient hospital care the patient may need (only for a set number of days, however, with the added bonus of copayments and deductibles...apparently there really is no such thing as a free lunch).

Part B (Medical Insurance): This part, which you must purchase, covers physicians' services, and selected other health care services and supplies that are not covered by Part A. What does it cost? The Part B premium for 2009 ranged from $96.40 to $308.30 per month depending on your household income.

Part C (Managed Care): This part, called Medicare Advantage, is a private insurance plan that provides all of the coverage provided in Parts A and B and must cover medically necessary services. Part C replaces Parts A & B. All private insurers that want to provide Part C coverage must meet certain criteria set forth by the government. Your care will also be managed much like the HMO plans previously discussed.

Part D (Prescription Drug Plans): Part D covers prescription drugs and costs $20 to $40 per month for those who chose to enroll.

Ok, now how does Medicare pay for everything? Hospitals are paid predetermined amounts of money per admission or per outpatient procedure for services provided to Medicare patients. These predetermined amounts are based upon over 470 diagnosis-related groups (DRGs) or Ambulatory Payment Classifications (APC's) rather than the actual cost of the care rendered (interesting way to peg hospital reimbursement...especially when the Harvard economist who developed the DRG system openly disagrees with its use for this purpose). The cherry on top of the irrational reimbursement system is that the amount of money assigned to each DRG is not the same for each hospital. Totally logical (can you sense our sarcasm?). The figure is based on a formula that takes into account the type of service, the type of hospital, and the location of the hospital. This may sound logical but often times this system fails.

Medicaid:

Medicaid is a jointly funded (funded by both federal and state governments) health insurance program for low-income families. Eligibility rules vary from state to state and factors in age, pregnancy, disability, income and resources. Poverty alone does not qualify an individual for Medicaid (there is currently no government-provided insurance for the American poor...despite the fact that almost all first world countries have such a system...enter the current health care debate) but is a significant factor in Medicaid eligibility. Each state operates its own Medicaid program but must adhere to certain federal guidelines to receive matching federal funds (you may be familiar with California's MediCal, Massachusetts' MassHealth and Oregon's Oregon Health Plan due to their recent media coverage). Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States.

How are the bills paid?

We now understand who is paying the bill but we have yet to cover how those bills are paid. There are two broad divisions of arrangements for paying for and delivering health care: fee-for-service care and prepaid care.

Fee-for-Service

As we mentioned briefly while discussing PPO's, in a fee-for-service structure, consumers select a provider, receive care (a.k.a. "service") from the provider, and incur expenses (a.k.a. "a fee") for the care. Deductibles and copayments are also required as previously discussed. Pretty simple. The physician is then reimbursed for their services in part by the insurer (i.e. a private insurance company or the government) and in part by the patient, who is responsible for the balance unpaid by the insurer (the return of the unanticipated medical bill despite your overpriced insurance). Again, the major downfall of the fee-for-service approach is that medical professionals are incentivized to provide services (and by this we mean any and all services they can legally request or must request to be protected legally), some of which may be nonessential, to increase their revenue and/or "C.Y.A." (revenue that has steadily decreased as insurance companies continue to lower the amount they pay medical professionals for their services).

Fee Schedule

A fee schedule operates in the same way that Fee-for-Service does with one exception: instead of using the "usual, customary, and reasonable" amount to reimburse medical professionals, states set fees to be paid for specific procedures and services. The reimbursement is very low ($.10-.15 on the dollar) and barely covers the actual direct cost of providing the care. Physicians may chose to opt into the plan or not (starting to see why a doctor might not be so excited about this plan?). Would you sign up to be paid 10 cents for every dollar you charged for your work? Try the insurance reimbursement approach next time you go out to eat. We'll come bail you out of the Big House if things go awry. What happens when the insurance system does this? You get the Wal-Mart approach to medicine (high volume, low quality). Not the kind of heath care we recommend.

Pre-Paid

Pre-paid health care? Like a phone card? Not exactly--but close. The pre-paid system evolved out of the insurance company's desire to share its risk ( a.k.a "pooled risk") with health care providers. Essentially, they wanted the doctors to have some skin in the game. In the pre-paid system, insurers make arrangements with health care providers to provide agreed-upon covered health care services to a given population of consumers for a (usually discounted) set price-the per-person premium fee-over a particular time period. What does that mean? It means that Dr. Bob gets paid, say, $30 per month to take care of Joe the Plumber including his blood work and x-rays. If Dr. Bob spends less than that caring for Joe, he makes money. If Joe is sick every month and needs lots of tests and follow-up visits, Dr. Bob could lose money caring for Joe. The set monthly fee paid to the doctor for taking care of a patient is set up on a per-member, per-month (PMPM) rate called a "capitated fee." The provider receives the capitated fee per enrollee regardless of whether the enrollee uses health care services and regardless of the quality of services provided (not a good thing in our book). Theoretically, providers should become more prudent and subsequently provide services in a more cost effective manner because they are bearing some of the risk. Often times, however, less care is provided than is needed in hopes of saving money and increasing profits. In addition, physicians are incentivized to cherry pick the youngest and healthiest patients because these patients typically require less care (i.e. they are cheaper to keep healthy). We like that doctors are encouraged to keep patients healthy but we have to worry about the ways in which they are being encouraged to reduce costs (as little care as possible?). Again, the incentive system falls short and encourages providers to act unethically.

The Take Home Message:

Health Care in the United States today is complex and messy at best. The layers on top of layers of failed attempts to correct the system continue to encourage the wrong behavior in both patients (out of fear of medical bills) and providers (out of fear of bankruptcy). We have yet to provide every American citizen with medical care (something that goes without saying in most 1st World countries...even Cuba has it!). We spend more money on caring for our citizens than any country in the world yet we continue to lag behind in terms of national health outcomes. We think it's safe to say that we're not getting the best bang for our buck. The ultimate solution? We wish we knew. Only time will tell where the system goes from here. Our goal: to help you better understand the system as it stands today in hopes of developing a more effective, efficient, and comprehensive system for the future. Are you with us?

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Health Care Fraud

The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the 'lions-share' of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with 'sleight-of-hand' precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

- "Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system... It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today... We pay these costs as taxpayers and through higher health insurance premiums... We must be proactive in combating health care fraud and abuse... We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud." [Senator Ted Kaufman (D-DE), 10/28/09 press release]

- The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year - or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don't know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care - vary from state to state and from payor to payor - are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers' services, many insurers instruct providers to report codes based on what the insurer's computer editing programs recognize - not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid - in some cases codes that do not accurately reflect the provider's service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage - especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government's reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws - presuming new laws will result in more fraud detected, investigated and prosecuted - without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments' capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What's one person's fraud (insurer alleging medically unnecessary services) is another person's savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

- DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

- REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn't paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient...

- REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

- PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

- PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters - steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud - on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

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Scandalous Scandos Part II

The fuck boat. The chlamydia cruise. The titstanic. (Ok that last one I made up). The viking line cruise from Finland to Sweden is known by many names, most of them skeezy. It's not really that hard to imagine to be fair. Take a few thousands georgeous Scandanavians, put them on a boat for 14 hours, add alcohol.... It's basically a porno plot.

So naturally I was looking forward to this cruise, especially since Jannica had managed to snag me a cabin so I actually had somewhere to sleep and put my bags. Unfortunately I realised the hard truth as soon as the ship took off, that while there may well be many STIs passed between shipmates on this boat, they were going to be between swinging 70 year olds, not the buxom Swedish masseuse team (they have competitions for that surely) I had imagined.

Actually it was for the best really. I was knackered after getting about 3 hours sleep the night before, and I could still taste strawberry and cream liquer from the night before. Luckily Jannica had managed to snag me a cabin so I had a bed to sleep on which was awesome. This I thought was very luxurious, right up until I realised I was on the floor below the livestock.

Seriously, this was the sign on the door on the level above mine.

So I went up to the top deck, watched the sunset, and then got a guy to take one last picture of me before I headed to bed....

Such good intentions

The guys who took my picture turned out to be poms and noticed my accent. We chatted for a bit, then they told me that they were going to get some dirty cheap brandy and have a few drinks. I decided to follow them, thinking that maybe one beer wouldn´t hurt. Then I found a bottle of jaeger for 15 euros that came with a free beanie!!!! The night sort of turned form there. I actually intended on just having one or two and saving it for Sweden, but that plan went out the window pretty quickly.

The cruise was hilarious, sort of like a mini scando vegas on a boat. They had a stage that just looked like it should have cabaret on it, but instead had a crooning Tina Turner lookalike, who sang polka music.

Pardon the shaky photo, I was polkaing.

It also had a karaoke bar, which bizarrely had goths singing tunes like the Bodyguard theme really really well.

After discussing the hilarity of singing the titanic tune while on a cruise we decided to move down to see Tina Turner do her thing. Down there we found that there were in fact five people between the ages of 18 and 30 on the boat when we met two cool Finn´s Elina and Katarina. From there the night sort of escalated. I dont remember the details but there was definitely polka dancing, karaoke music, and my Jaeger was gone by 10pm.... After being so excited about having a cabin I ended up getting about one hours sleep, and ended up being the skeeziest person exiting a boat that had just housed an octagenarian orgy.

Adding to my sense of shame for my attrocious condition was that I had just entered one of the most beautiful cities I've ever visited. I had mainly come to Stockholm to visit my old uni mates Henrik, Boris and Ani, but man am I glad I came. Stockholm is just georgeous. Trust the swedes to make a city to accesorise their chiseled features. The city is made up of the old city on an island at the centre featuring typical ye olde euro cobblestones, thin winding streets etc. Then the surrounding areas, despite not living up to the 'old' tag of the old city, are all just as amazing.

Classic swedish ass

Ye olde 7 eleven

Nobel Museum, and me looking all smart like

Town Hall, where the nobels are handed out.

Everything about this city is just beautiful. Science tells us that the average single Aussie male falls in love about once every 2 minutes while walking around Stockholm. I also loved the number of cyclists sharing the roads with the cars with zero road rage (the Scandanavians dont have a word Alan Jones). But my favourite bit of the city had to be the underground track which they've dug out of the bedrock and decided to let artists have at it creating just an awesome public art experience. It's just small things like this that I love and that can transform a city.

had to be done

This one had all the major historical events from recorded history along the walls, the skull for the plague was a nice touch.

I was lucky enough to have two lots of awesome tour guides, first the Finns from the boat showed me around, and then a couple of my couchsurfers from Newcastle stayed with me. My couchsurfers are three girls (though one couldnt make it) who my friend Gav and I had an awesome time with one weekend last year, the highlight of which was definitely catching them on camera singing Waterloo.

As I said earlier, I was mainly there visiting my uni mates, Henrik (swedish accountant), Boris (Aussie plying the Aussie accent on lovely Swedish girls), and Ani (Henrik's gf and ex Lander tennis player as well). Henrik and Ani were nice enough to let me crash on their couch the whole time I was there, give me a mobile to use while I was in town, and generally just be amazing hosts. The two nights I was in town we went out for a few beers, which ended up being alot each time, which was  then added to while meeting my two lots of tour guides afterwards for more drinks. This definitely didn't help my budgeting for my trip, but it was a great time. The most magic moment was definitely when Henrik ordered himself a lovely drink that would've fit right in with the shots I did in Hanko, and then managed to pair this moment of getting in touch with his feminine side with a very masculine nose pick, all caught on camera.

Anyway, it's about 4am again, and I should get some sleep. Tomorrow (today really, we're 1/6th of the way into it) is my last day in Norway, and I'll hopeully be able to update you on the amazing time I've had here in the next couple of days.
Caedyn

More about → Scandalous Scandos Part II

About this Blog

Hi. Just writing this for those new to my travel writings as a bit of a warning/guide.

You may have noticed that each of my posts so far have taken longer to read about than the events actually took to happen. This is for a few reasons, but mainly because I love to talk, at length, and in letters/blogs there's none of that pesky "listening" crap I have to endure before talking some more. But they're also really long because they're mainly for my mum. She doesn't seem to mind spending a lot of time reading my stories (she's says my writing is up there in entertainment value with some of her law books!) and as much as I love travelling I hate being away from my family and feel sort of guilty about it. So yeh, they're going to be long posts. If your not my mum, or can't speed read, but still like me enough to want to know a little about what I've been up to I recommend looking at the photos and maybe using your find function for keywords such as "beers", "amazing scenery" or "deceptively feminine lady boys" to find parts of my tales that you may enjoy. Otherwise I apologise and promise to try and make it at least a little interesting.

Secondly, I've got a couple of other things I want to do with this blog. Firstly, I'm coming up with a new cliches for each country while I'm on this trip. The old cliches are tired and causing a new generation to suffer for the patterns of their grandparents. Maybe this will mean that one day Aussie's wont feel the need to be massive bogans when they travel? This idea came about when I had a Danish backpacker and a German backpacker staying with me. The Danish girl informed me that whenever a German goes to the beach, they dig a hole and sit in it. Rather than refute it the German girl replied "Vell vat else do you do with a hole?" Magic!

That, and I also may try and write my own backpackers guide of the world I've been to. I guess that'll depend how much time I have on long bus and train trips, but if I find time I'll give it a shot.

Anyway, last thing I guess is an apology to all the unreturned facebook messages I have and will no doubt receive. I'm lucky enough to have a tonne of really good friends who care enough to ask me how things are going. Unfortunately I am now without a smart phone (I feel like I'm naked) and can't message you as easily as before, but hopefully this blog will keep you updated enough, and I can make it up to you when I get back over a few beers. But please, keep messaging me and let me know how everything is going back in Aus!

Well that's it. Thanks for reading!

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Scando Uni Mates: How to blow half your budget in your first month of backpacking

Well I'm in, on European time, and starting to feel a bit like a traveller. Actually I feel like I'm back at uni. So far I've stayed in three places, and each time it's been with an old College mate. I've read before that when you travel you'll spend twice as much money when you're with mates than when you're alone. I've also heard that Scandanavia is by far the most expensive place in the world to travel in. These are the only two facts which keep me from crying, rocking back and forward holding my knees every time I check my bank balance over here. The following are the awesome times I've blown my wad on.

First expensive scando country was Finland. Actually, Finland wasn't that expensive. Actually they're not even real scandanavians. Don't ever mention this within arms reach of one, but Finland is basically the lovechild of Scandanavia and Russia. They deny it, but there are statues of guys called Alexandr everywhere and they're really good at hockey = Russians. I stayed with my old college roomy Jannica. It's been absolutely ages since we've seen each other, but like all good friends it was pretty much straight back to where we left off: lots of banter, and her making me sandwiches and cleaning up after me. Unfortunately we also picked up where we left off with Jannica's football career. Back when we were at Lander, Jannica kicked a whole lot off arse as the ladies soccer teams striker. Unfortunately I was her kryptonite. I have never seen her score a goal, and the chances she's managed to miss have been comical. Others assure me that she can in fact kick a ball into an open net, but not while I'm about. This trend continued as poor Jannica hurt her foot right before I got there and was the saddest soccer player at training ever.

Apart from Jannica's foot, Finland was amazing. The people were lovely (apparently seeing the sun for the first time in 6 months makes them especially happy) and typically scanadanavianly beautiful, the food was awesome, and the alcohol plentiful. I spent the first few hours in Helsinki, which is classic euro city. Cobble stones in the old parts, beautiful architecture, buildings older than Australia, and immovable guards standing outside their dignitaries homes.

Fact: Guards love this

We then went back to Turku which is where Jannica lives with her now fiance Teppo. Teppo is awesome, and was great to hang out with. He's a chef, so not only did I get pampered by Jannica, but Teppo also just casually knocked up a gourmet feast one of the nights I was there. The two of them showed me around the town, we caught a few hockey games on tv (the world champs were being held in Finland when I was there and the Finns were going crazy for it) and very generously took me to an Aussie bar to see the very people I was trying to run away from (not you guys reading thid of course). Luckily they had one non Aussie beer there: Karhu - the only beer made for bears in handy 1L cans.

KARHU! So manly, engaged women are forbidden from looking at it.

I even caught a few of Jannica's training sessions where I got to learn how to use my camera a bit (photographing Scandanavian female athletes, someone has to do it) and met up a few times with one of Jannica's old friends, and team mate Anne Sofie (who I originally bonded graffitiing her good friends face in America...funnily enough that friend didn't come see me...). 

Anne Sofie on the left

After taking in Turku and basically hanging with Jannica and Teppo, Jannica and I went down to her hometown Hanko. Hanko is a really pretty beach town on the southern most mainland part of Finland (ha, bet you didnt think you'd learn stuff here aye). In Hanko I caught up with Jannica's mum, who is possibly my second favourite mum in the world. I met Mrs Finnberg (yeh, that's not a nickname, Jannica the Finn's surname is Finnberg. "Hi I'm Caedyn Ausberg") when she came to Jannica's graduation. We speak pretty much none of the same language as each other, but we both think that's pretty funny, so it's always lots of laughs when we're around each other. We met her at the service station she owns and she attempted to load me up with enough provisions for the rest of my 11 months travelling (btw I'm writing this in Norway and I should have taken her up on that). 

From there we went to Jannica's house to pregame for a party thaty night and to have a sauna....because Finns have sauna's in their houses!

After sweating out all the bad stuff from my body (vegetables, vitamins, etc) I then headed off with Jannica to our old friend Shady Pies. Her real name is Heidi or something like that, but no one who actually knows her would ever call her that. Shady just happened to be throwing a house party with a whole bunch of her beautiful Finnish girl friends. Crashing a girls night in scandanavia has obvious upsides:

With only one real downside, being made to drink fancy girl shots with lots of cream to go with my KARHU!! I had earlier:

Ah who am I kidding, they tasted like happiness.

As a first big night out it was definitely far more upper crust than I expected, and it was awesome catching up with the girls and seeing they were just as insane in Finland as they were in America. I'd love to tell you more stories about the night, but all I really recall was having dreams about my mouth being coated with strawberry jam. The next day I didn't feel crash hot until I realised my view was this:

 That combined with some loud punk music perked me right up, and Jannica and I raced around Hanko being tourists, and taking advantage of the balmy 17 degrees temperatures. I got to see where she'll make a very lovely bride in 15 months time, and where the reception will be after. She informed me that this therefore meant I had no further obligations to attend her wedding, and that she wouldn't never talk to me again if I didn't come. Brides...so understanding.

Maybe I can skype attend?

Sightseeing with Caedyn

After that it was back to Turku, stopping off one more time to say bye to Mrs. Finnberg, and then I reluctantly had to say my goodbyes to Jannica after a great start to the trip. I really can't thank Jannica (and Teppo) enough, but I think this drunken photo goes some of the way.

More about → Scando Uni Mates: How to blow half your budget in your first month of backpacking