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04/25/12

  05:10:13 pm, by MedBen5   , 428 words,  
Categories: News, Health Plan Management

SBC Requirements for Health FSAs

As we’ve noted in earlier blog posts, the Affordable Care Act has imposed a significant new disclosure requirement: the Uniform Summary of Coverage document. Known as a Summary of Benefits and Coverage (SBC), the document must contain a standardized overview that individuals can use to uniformly compare health care plan offerings. MedBen is in the process of preparing these for clients.

The federal government has issued final regulations and related guidance implementing this requirement. Included in these regulations are explanations of how consumer-driven health plans (CDHPs) fit into the SBC model. Below, we examine what types of health flexible spending accounts (FSAs) are excepted from the requirements.

A health FSA is excepted – that is, a SBC does not need to be provided – if these two conditions are met:

1. Maximum Benefits Condition – The maximum benefit payable from the health FSA does not exceed the greater of:

  • Two times the employee’s salary reduction election; or
  • The amount of the employee’s salary reduction for the year plus $500.

Put another way:

  • If the employer contribution is $500 or less, the Maximum Benefit Condition HAS been met. But if the employer contributed more than $500 and the employee contributed $500 or less (i.e., employer $600, employee $400), the condition HAS NOT been met.
  • If the maximum benefit payable for employee and employer is a one-for-one match – for example, if the employee can contribute up to $600, and the employer matches that $600 – the Maximum Benefit Condition HAS been met. But if the employer contributed $700 – a contribution in excess of a one-to-one match – the condition HAS NOT been met.

A health FSA funded solely by employee contributions would, by definition, satisfy this condition.

2. Availability Condition – Other non-excepted group health plan coverage (e.g., major medical coverage) must be made available to the same class of participants by reason of their employment. (The regulations do not define “class of participants”, but at this time we presume that they refer to distinctions in coverage availability between, say, full-time employees eligible for both major medical and health FSA participation, and part-time employees eligible only for the health FSA.)

If a non-excepted health FSA is integrated with other major medical coverage, information about it can be included in the appropriate spaces on the major medical SBC for deductibles, co-payments, co-insurance, and benefits otherwise not covered by the major medical coverage. But if a stand-alone health FSA doesn’t satisfy the two conditions, a separate SBC must be provided.

MedBen clients with questions about health FSAs in relation to the SBC document can call Sharon A. Mills, Director of Administrative Services, at (800) 423-3151, Ext. 438.

04/23/12

  04:43:21 pm, by MedBen5   , 183 words,  
Categories: News, Health Plan Management

HHS Updates Listing of Counties for “Culturally and Linguistically Appropriate Services”

Earlier this month, Health and Human Services (HHS) released its 2012 listing of United States counties in which non-grandfathered self-funded health plans and fully-insured policies must provide certain plan notices, including appeals and external review documents, EOBs, and the new SBC document, in a “culturally and linguistically” appropriate manner. Simply put, this means that these documents must be translated into one of four specific languages (Spanish, Chinese, Tagalog and Navaho) if that language is the predominant non-English language spoken by more than 10% of the residents in that county (based on U.S. Census Bureau data).

How do you know which languages are predominantly spoken by more than 10% of the population in any county? HHS has posted the listing of which counties meet or exceed the 10% threshold at http://www.cciio.cms.gov/resources/factsheets/clas-data.html.

If you’re a MedBen client who has plan participants in any of the counties listed, please let us know and we will help you find resources for getting the required plan documents translated. Clients with additional questions may contact MedBen Vice President of Compliance Caroline Fraker at (800) 851-0907.

  02:44:30 pm, by MedBen5   , 182 words,  
Categories: News, Prescription

FDA Responds To Criticisms Of Drug Tracking Efforts

The U.S. Food and Drug Administration has responded to criticisms that it fails to track the safety of drugs after they are approved. According to Reuters, the agency said this weekend that it spends an equal amount of effort and resources on surveilling a drug post-approval as it does prior to authorization.

Before 2008, the FDA could not force drugmakers to revise labels or perform additional tests after approval of a medication. But Congress gave the agency more power to oversee drugs after approval – and since 2008, it says it has required companies to do 385 post-market studies, and change their labels 65 times.

The criticism of the FDA was due largely to the agency’s slow response to reports of side effects in the painkiller Vioxx and other drugs. To be more proactive in such matters, in 2008 it launched Sentinel, a computer tracking system that searches databases for potential side effects in approved medications.

“We think we’ve really balanced this,” Dr. Janet Woodcock, director of the agency’s Center for Drug Evaluation and Research, told reporters attending the Association of Healthcare Journalist meeting in Atlanta.

  12:17:46 pm, by MedBen5   , 142 words,  
Categories: News, Health Plan Management

Romney's Reform Proposal Would Emphasize Individual Coverage

“Repeal and replace” the Affordable Care Act has been a mantra for Mitt Romney’s presidential campaign. But the presumptive GOP candidate has his own ideas for health care reform on a nationwide scale.

The Los Angeles Times reports that while Romney’s proposal has yet to be fully fleshed out, its main selling point is giving Americans a tax break to buy their own health plan – thus emphasizing individual coverage over employer-based plans.

Conservative health care experts say that giving people a greater role in choosing their coverage would encourage greater competition, thus reducing costs. Critics of the proposal and independent analysts counter that it would likely leave a larger number of Americans without insurance.

According to the Times article, Romney’s proposal would also give companies strong incentives to stop providing coverage to employees, as well as overhaul Medicare and Medicaid programs.

04/20/12

  05:00:34 pm, by MedBen5   , 333 words,  
Categories: Announcements

MedBen Adds Davis to Sales and Marketing Team

Pam Davis

MedBen is pleased to announce the addition of a new associate to its Sales and Marketing team. Pamela Davis will serve as Regional Sales Manager in Southeastern Ohio and West Virginia, assisting her region’s broker network with the sales of all MedBen product lines.

As a health care industry veteran with 25 years experience, Pam brings a wealth of employee benefits knowledge to her position – and not just in sales. She is also well-versed in the daily workings of PPOs and utilization review services, in addition to marketing, group administration and human resources.

Even though Pam has just joined the MedBen team, you may already be familiar with her and her work. In her previous job with Quality Care Partners, a prominent Southeastern Ohio physician-hospital organization, she provided consultative services for self-funded employers and insurance brokers in Southeastern Ohio for over 15 years.

In her prior position, Pam also teamed directly with MedBen and its agent network on numerous occasions, meeting with clients to provide useful plan performance analyses. As a result, she has established relationships with many of the people she’ll be working with on our behalf. And she will continue to function as a partner to QCP in the areas she serves.

Speaking of partners… among Pam’s primary responsibilities will be to oversee the continued growth of Partners Community Health Plan. Offered in conjunction with MedBen and local hospitals, this unique product has found popularity throughout Southeastern Ohio since its introduction in 2010. Pam will work with brokers and hospitals to raise awareness of Partners in its current regions and assist with its expansion into new territories.

Pam also has an extensive understanding of self-funded health plans, and will be responsible for sales efforts in that area. Additionally, she will represent MedBen’s full line of products, including dental, vision, consumer-driven health plans and worksite wellness programs.

Pam is a graduate of Muskingum Area Technical College (Zane State). She resides in Nashport, Ohio with her husband, Mike, and their two sons.

  04:57:03 pm, by MedBen5   , 210 words,  
Categories: News, Wellness

Does Provider Emphasis On Well-Being Reduce Health Care Costs?

An interesting article in the Wall Street Journal that ties (tangentally, anyway) into yesterday’s Patient-Centered Outcomes Research Institute post: Instead of focusing only on blood pressure, cholesterol levels and other indicators of one’s health, health care providers are encouraged to talk with patients about how their health affects their quality of life.

From the article:

“[Health care providers] are pushing for programs where nurses or trained counselors meet with people and ask personal questions like: Is your condition inhibiting your life? Is it making you less happy? Does it make it hard to cope day to day? Then the counselors offer advice about managing those problems and follow up regularly.

“The logic is simple. People are more likely to manage their condition properly when they have more accessible, personal goals, like being able to do more at work or keep up with their kids, instead of focusing only on comparatively abstract targets like blood-sugar levels. And that, in turn, leads to much better health. Numerous studies show that when people have a higher sense of well-being, they have fewer hospitalizations and emergency-room visits, miss fewer days of work and use less medication. They’re also more productive at work and more engaged in the community.”

Read more at the WSJ website.

  04:17:30 pm, by MedBen5   , 147 words,  
Categories: News, Wellness

Daily Exercise May Help Smokers Kick The Habit

Nicotine gum and patches may or may not aid cigarette smokers in kicking the habit, but a major study suggests that exercise may be an effective route to quitting once and for all.

According to NPR, researchers in Taiwan tracked the health and habits of 434,190 people in Taiwan from 1996 to 2008. They found that smokers who exercised for as little as 15 minutes a day were 55% more likely to quit than inactive people. And by staying active, ex-smokers were 43% less likely to relapse later.

Not only did a daily workout help smokers give up cigarettes, it also counteracted the negative effects of the habit. Just 30 minutes of exercise a day increased the life of ex-smokers by 5.6 years, while reducing their risk of death by 43%.

And even smokers who haven’t successfully quit benefit from keeping active. The study found that a daily 30-minute walk increased their life expectancy by 3.7 years.

04/19/12

  05:07:13 pm, by MedBen5   , 458 words,  
Categories: News, Health Plan Management

New Employer Tax to Fund Patient-Centered Outcomes Research

Last week, the Internal Revenue Service released its pre-Federal Register draft of proposed rules on how self-funded plan sponsors and insurance carriers will pay the federal government to support the Patient-Centered Research Outcomes Institute. The Affordable Care Act (ACA) amended the Internal Revenue Code to create the Patient-Centered Outcomes Research Institute Trust Fund and the taxes collected will fund the Trust between 2012 and 2019. The Institute is tasked with conducting research to evaluate the clinical effectiveness of certain medical treatments, services and supplies, as well as reviewing strategies to treat, diagnose and manage illness and injury.

Unlike the discussions during the Supreme Court hearings as to whether the fee charged for not purchasing coverage under the ACA’s Individual Mandate is really a “tax” or a “penalty”, the IRS considers this Trust Fund payment a “tax” and treats it as such under the proposed regulations. You might also have heard this tax called the “Comparative Effectiveness Fee”.

The proposed regulations are based on comments received after the IRS released Notice 2011-35 in June, 2011 regarding implementation of the tax. The Trust Fund tax remains in effect for plan/policy years beginning after September 30, 2012 and continues through the 2018 plan/policy year. The proposed regulations require that the first payments be made in July, 2013 and require submission of IRS Form 720 (Quarterly Federal Excise Tax Return) along with the payment. For the Trust Fund Tax payments only, Form 720 must be filed annually – although Form 720 may need to be filed by a company quarterly for other purposes.

Full story »

04/18/12

  05:31:55 pm, by MedBen5   , 195 words,  
Categories: News, Wellness, Health Plan Management

Eye Screening May Reveal Onset of Parkinson's

Considering that vision exams can detect diabetes, high blood pressure, high cholesterol, glaucoma, multiple sclerosis and even potential memory loss, it would not be hyperbole to say that our eyes can serve as a treasure trove of medical information. MedPage Today reports on still another condition that a more advanced eye screening may uncover: Parkinson’s disease.

According to a study of 112 Parkinson’s patients, including newly diagnosed cases not yet on medication, all tested showed constant small rhythmic movements of their eyes when attempting to fix their gaze on an object. By comparison, the same instability was seen in just two of 60 age-matched controls.

Co-researcher Mark S. Baron, MD, of the VA Medical Center in Richmond, Va. says that while specialty equipment is needed to measure the eye tremors, the screening could be nearly 100% accurate.

Studies like this demonstrate the usefulness of regular eye checkups. That’s why MedBen VisionPlus promotes regular exams and early detection and treatment of visual impairments. Our group vision plan also provide the highest quality glasses and contact lenses at extremely affordable prices.

To learn more about MedBen’s vision care programs, contact Vice President of Sales and Marketing Brian Fargus at (888) 627-8683.

  04:11:44 pm, by MedBen5   , 189 words,  
Categories: News, Health Plan Management

Labor Department Updates Online Employer Health Benefit Advisor

The U.S. Department of Labor (DOL) has released an updated version of its Health Benefits Advisor for Employers. This online resource outlines the federal laws that can affect health benefit coverage provided by group health plans. The Advisor explains the legislation, statutes and regulations in Parts 6 and 7 of Title I of the Employee Retirement Income Security Act of 1974 (ERISA). These laws include:

  • Consolidated Omnibus Budget Reconciliation Act (COBRA)
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Mental Health Parity Act (MHPA) and Mental Health Parity and Addiction Equity Act (MHPAEA)
  • Newborns’ and Mothers’ Health Protection Act (Newborns’ Act)
  • Women’s Health and Cancer Rights Act (WHCRA)
  • Genetic Information Nondiscrimination Act (GINA)
  • Michelle’s Law

You may access the updated Health Benefits Advisor for Employers from the DOL web site at http://www.dol.gov/elaws/ebsa/health/employer/.

The Health Benefits Advisor for Employers is one of a series of elaws (Employment Laws Assistance for Workers and Small Businesses) Advisors developed by DOL to help employers and employees understand federal employment laws and resources. To access all of the elaws advisors, visit the elaws Web site at www.dol.gov/elaws.

04/17/12

  04:47:27 pm, by MedBen5   , 144 words,  
Categories: News, Wellness

Study: Obesity Accounts For One-Fifth Of U.S. Health Spending

Carrying around excess weight is a financial burden in addition to a physical one, a new study says.

According to HealthDay News, researchers from Cornell University found that an obese person’s medical costs are $2,741 a year higher (in 2005 dollars) than if they were not obese. That additional money adds up to $190.2 billion a year nationally – nearly 21% of total U.S. health spending.

The study’s numbers far exceed previous estimates that put the cost of obesity at $85.7 billion a year. “Historically, we’ve been underestimating the benefit of preventing and reducing obesity,” study author John Cawley said in a university news release.

“Obesity raises the risk of cancer, stroke, heart attack and diabetes,” Cawley said. “For any type of surgery, there are complications [for the obese] with anesthesia, with healing. Obesity raises the costs of treating almost any medical condition. It adds up very quickly.”

04/13/12

  04:54:40 pm, by MedBen5   , 205 words,  
Categories: News, Wellness

Working The Late Shift May Raise Diabetes Risk

More evidence that irregular sleep habits can adversely affect one’s health: A new study by Brigham and Women’s Hospital in Boston found the fighting the body’s natural sleep patterns can increase the risk of type 2 diabetes.

According to MSNBC, researchers deliberately disrupted the normal sleep patterns of volunteers. Within a few days, their bodies began to respond differently to standard meals – so much so that three of the volunteers became pre-diabetic. Fortunately, symptoms disappeared when regular sleep resumed.

“Glucose levels went much higher and stayed that way for several hours,” said neuroscientist Orfeu Buxton, Ph. D., the study’s lead author. “This was because of decreased insulin released from the pancreas. Together these reflect an increased risk of diabetes.”

More than 21 million Americans who labor evening or nighttime hours have a righer risk of obesity and heart disease, in addtion to diabetes. The advice from the scientists for those who perform “shift work” – either out of necessity or choice:

  • Try to make your daily clock as normal as possible.
  • Get good sleep during the day – finding, if you can, a quiet, very dark room.
  • Don’t eat big meals at a time when you feel your body clock is out of whack.

04/11/12

  04:42:13 pm, by MedBen5   , 176 words,  
Categories: News, Health Plan Management

Support For Health Care Reform Law Continues To Fall

Public support of the health care reform law has reached a new low, according to the latest ABC News/Washington Post poll.

ABC News reports that 53% now disapprove of the Affordable Care Act, while only 39% support it – the smallest vote of confidence in more than a dozen such polls since August 2009. “Strong” opposition outnumbers strong advocacy by over a 2-to-1 margin.

Moreover, a combined two-thirds of respondents believe that the Supreme Court should strike down the entire law (38%) or at least the individual mandate (29%), the requirement that most Americans carry health insurance or pay a penalty.

As for how people think the high court will vote on the ACA, over half think the justices will allow partisan political views to influence their ruling, while 40% say the decision will be impartial. Along party lines, 41% of Republicans say the vote will be partisan, compared to 55% of Democrats and 52% of independents.

A bit of good news for President Obama, however: 48% of reposdents trust his handling of health care policy, compared to just 38% for presumptive GOP nominee Mitt Romney.

  10:43:07 am, by MedBen5   , 212 words,  
Categories: News, Wellness

Cancer Headlines: Higher Costs, Higher Survival Rates

Lots of cancer-related news this week… here’s a sampling:

  • According to Kaiser Health News, a new study suggests that higher American costs for cancer care compared to Europe is offset by better U.S. survival rates – almost two years longer on average. “We found that the value of the survival gains greatly outweighed the costs, which suggests that the costs of cancer care were indeed ‘worth it,’” the researchers wrote.
  • The U.S. Preventive Services Task Force has renewed its 2004 recommendation that women at average risk for ovarian cancer not get screened for the disease, Medical Xpress reports. The panel says that the currently used blood test and transvaginal ultrasound isn’t very accurate, and as such may cause more harm than benefit for patients.
  • Reuters reports that people are more likely to get screened for colorectal cancer when their doctors recommend they get a stool test instead of a colonoscopy, or when doctors leave it up to patients to choose which test to have. A new study suggests that doctors should take their patients’ preferences into consideration before recommending one test or the other.
  • And via USA Today: The American Cancer Society reminds people that proper diet and other healthy lifestyle habits can greatly reduce the odds of developing the disease.
  09:54:42 am, by MedBen5   , 177 words,  
Categories: News, Wellness

Tried-and-True Weight Loss Methods Work Best, Study Finds

Every now and then, the scientific community takes a few moments out of their busy schedule to confirm something that we all already know… but hey, a gentle reminder never hurts. In this case, a new study determined that time-tested ways of losing weight – exercise, eating less fatty food and so on – work better than fad diets and “miracle” weight-loss pills.

WebMD reports that researchers analyzed surveys from over 4,000 obese people to determine how those who successfully lost weight did so. They found that those who exercised more and ate less fat lost more weight.

“People actually are losing 5% to 10% of their body weight or more using tried-and-true methods,” says study author Jacinda M. Nicklas, MD, MPH of Beth Israel Deaconess Medical Center in Boston.

The study also showed that people who joined commercial weight loss programs, such as Weight Watchers or Jenny Craig, were more likely to lose 10% or more of their body weight. And while only a small portion of those surveyed used prescription weight loss drugs, most did report some weight loss.

04/10/12

  05:38:00 pm, by MedBen5   , 213 words,  
Categories: News, Health Plan Management

New Medical Codes Delayed Until 2014

The Department of Health and Human Services (HHS) has announced that an upgrade to the medical-coding standard will be postponed for a year, The Wall Street Journal Health Blog reports.

Originally set for implementation in 2013, the coding set known as will now go into effect on October 1, 2014. In a press release, HHS said the delay will give doctor and health insurers “more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.”

When the ICD-10 update is completed, the number of diagnosis and procedure codes used in medical billing will expand greatly, from around 18,000 in the current ICD-9 code set to about 140,000. Not surprisingly, the American Medical Association doesn’t favor the change, saying that the increase in codes will further burden doctors without improving care.

HHS said that the proposed coding changes – which would also establish a unique health plan identifier that could be used in billing – “would save health care providers and health plans up to $4.6 billion over the next ten years.”

To get some idea of the scope of the 120,000+ new codes, take a look at this Wall Street Journal article from September 2011. Suffice it to say, if you’re ever burned by flaming waterskis, there’s a code for that.

  01:02:59 pm, by MedBen5   , 295 words,  
Categories: Wellness, Health Plan Management

Doctors Differ In Opinion Of "Choosing Wisely" Campaign

Last week, nine medical societies jointly announced “Choosing Wisely” – a doctor-focused campaign to promote more selective use of medical tests. The groups compled a list of 45 tests and procedures they considered to be overused.

On the KevinMD.com blog, two physicians share their opinions of Choosing Wisely – one approving, the other more qualified in his support:

John Mandrola, MD, cardiologist: “Doctors must design and implement healthcare changes and reforms. Call us what you will, but we are the experts in medical diagnosis and treatments. We know what works and what doesn’t. We must be allowed to practice Medicine – not just follow protocols, or test and treat just to cover our butts. The corollary here, of course, is that we must be allowed to be human…

“That our thought leaders are now proclaiming – and social media is amplifying – the values of clinical judgment and targeted thoughtful diagnostic and therapeutic interventions represents a monumental sea change.”

Mike Sevilla, MD, family physician: “With these reports today, patients are challenging me even harder about the testing and treatments that I am recommending. I don’t have a problem with this. However, I do have a problem how this story has been framed in that ‘I’ am the reason why unnecessary tests are done, and my patients are more than happy to remind me of that…”

“Now, don’t get me wrong. I agree with everything that happened today. 30 billion dollars annually of unnecessary tests are a real problem. However, will this effort really change the behavior of physicians? Probably not. Will this effort really try to educate patients not to ask for unnecessary tests? Probably not. Will this campaign hope to score political points with Congress and the White House? Some believe yes…”

  11:22:15 am, by MedBen5   , 219 words,  
Categories: Announcements, News, Health Plan Management

Report: Health Care Reform Law Would Raise Deficit

The Affordable Care Act will add more that $340 billion to the deficit, according to a new study of the health care reform law by a Republican member of the board that oversees Medicare financing.

The Washington Post reports that conservative policy analyst Charles Blahous predicts that much of the savings and revenue ACA gains – from lower Medicare payments and higher taxes – will be more than offset by additional benefits to individuals already insured, paid through the Medicare hospitalization trust fund. That means those savings would not be available to pay for expanding coverage for the uninsured.

“If one asserts that this law extends the solvency of Medicare, then one is affirming that this law adds to the deficit,” said Blahous, who President Obama approved in 2010 as the GOP trustee for Medicare and Social Security. “Because the expansion of the Medicare trust fund and the creation of the new subsidies together create more spending than existed under prior law.”

The Obama administration countered that Blahous used faulty and selective math to reach his conclusions. “The fact of the matter is, the Congressional Budget Office and independent experts concluded that the health-reform law will reduce the deficit,” a White House budget official said, speaking to the Post on the condition of anonymity because the report was not publicly available.

04/09/12

  12:16:07 pm, by MedBen5   , 209 words,  
Categories: News, Wellness

Study Suggests False-Positives Can Predict Breast Cancer Risk

An oft-cited concern by those in support of reduced mammogramy screening is the greater potential of a “false-positive” – a result that indicates that a cancer is present when it is not. And indeed, 61% of women in the U.S. who do receive annual mammograms have at least one such incorrect result within a ten-year period.

New research suggests, however, that even false-positives may provide some hint for a future risk of breast cancer. Women in a Danish study who had at least one false-positive mammogram had a 67% greater likelihood of eventually being diagnosed with the disease, WebMD reports. The analysis included 58,000 women who had mammograms in Denmark between 1991 and 2005.

Breast cancer specialist Stephanie Bernik, MD doesn’t wholly support the study’s findings. “There has long been a suggestion that women who have more activity in their breasts that lead to false-positive mammograms may also have an increased risk for breast cancer, but I don’t think this study proves this,” she told WebMD.

Bernik (who was not involved in the research) also noted that innovations in mammography screening since 2000 have led to better detection of breast cancer and fewer false-positives, and the analysis reflects the greater test accuracy. “This study could be interpreted as reassuring for women being screened today.”

  11:23:55 am, by MedBen5   , 277 words,  
Categories: Health Plan Management

Health Care Woes In 1933 Sound Very Familiar

The more health care changes, the more it stays the same… at least, that’s the conclusion one might reach when reviewing a list of U.S. health care problems from 1933.

C.E.A. Winslow, a Professor of Public Health at Yale University, wrote “A Program of Medical Care for the United States” for the January 27, 1933 edition of Science magazine. His observations about the state of health care back then should strike a familiar chord with you. We’ve highlighted several here – you can read Winslow’s complete list at John Goodman’s Health Policy Blog.

  • Unwise expenditures for medical care: “Of the total of $3,656,000,000 a year now spent by the American people for medical care, 360 million dollars go for “patent medicines” and 125 million dollars for the services of cultists and irregular practitioners who have never studied the human body and do not understand its working.”
  • Economic burden of emergency illness: “in the group of families with incomes under $2,000 a year (about half the population of the United States) one per[cent]…of the families spent over $500 in one year for medical care…[this] constitutes the critical economic problem in the field of medical care.”
  • Inadequate care of the sick: “The second result of economic maladjustment is that a shocking large amount of illness is now actually uncared for (in spite of the potential adequacy of the resources at our disposal).”
  • Lack of preventive services: “…there is everywhere a grave lack of the applications of modern medical science to the prevention of disease…[A]s long as preventive services are immediately contingent on the payment of a fee for such services…they will not be sought by the patient.”

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