Health Savings Accounts – An American Innovation in Health Insurance

INTRODUCTON – The term “health insurance” is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government. Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits” and “medical insurance.” In a more technical sense, the term is used to describe any form of insurance that provides protection against injury or illness.

In America, the health insurance industry has changed rapidly during the last few decades. In the 1970’s most people who had health insurance had indemnity insurance. Indemnity insurance is often called fee-forservice. It is the traditional health insurance in which the medical provider (usually a doctor or hospital) is paid a fee for each service provided to the patient covered under the policy. An important category associated with the indemnity plans is that of consumer driven health care (CDHC). Consumer-directed health plans allow individuals and families to have greater control over their health care, including when and how they access care, what types of care they receive and how much they spend on health care services.

These plans are however associated with higher deductibles that the insured have to pay from their pocket before they can claim insurance money. Consumer driven health care plans include Health Reimbursement Plans (HRAs), Flexible Spending Accounts (FSAs), high deductible health plans (HDHps), Archer Medical Savings Accounts (MSAs) and Health Savings Accounts (HSAs). Of these, the Health Savings Accounts are the most recent and they have witnessed rapid growth during the last decade.

WHAT IS A HEALTH SAVINGS ACCOUNT?

A Health Savings Account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States. The funds contributed to the account are not subject to federal income tax at the time of deposit. These may be used to pay for qualified medical expenses at any time without federal tax liability.

Another feature is that the funds contributed to Health Savings Account roll over and accumulate year over year if not spent. These can be withdrawn by the employees at the time of retirement without any tax liabilities. Withdrawals for qualified expenses and interest earned are also not subject to federal income taxes. According to the U.S. Treasury Office, ‘A Health Savings Account is an alternative to traditional health insurance; it is a savings product that offers a different way for consumers to pay for their health care.

HSA’s enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.’ Thus the Health Savings Account is an effort to increase the efficiency of the American health care system and to encourage people to be more responsible and prudent towards their health care needs. It falls in the category of consumer driven health care plans.

Origin of Health Savings Account

The Health Savings Account was established under the Medicare Prescription Drug, Improvement, and Modernization Act passed by the U.S. Congress in June 2003, by the Senate in July 2003 and signed by President Bush on December 8, 2003.

Eligibility –

The following individuals are eligible to open a Health Savings Account –

– Those who are covered by a High Deductible Health Plan (HDHP).
– Those not covered by other health insurance plans.
– Those not enrolled in Medicare4.

Also there are no income limits on who may contribute to an HAS and there is no requirement of having earned income to contribute to an HAS. However HAS’s can’t be set up by those who are dependent on someone else’s tax return. Also HSA’s cannot be set up independently by children.

What is a High Deductible Health plan (HDHP)?

Enrollment in a High Deductible Health Plan (HDHP) is a necessary qualification for anyone wishing to open a Health Savings Account. In fact the HDHPs got a boost by the Medicare Modernization Act which introduced the HSAs. A High Deductible Health Plan is a health insurance plan which has a certain deductible threshold. This limit must be crossed before the insured person can claim insurance money. It does not cover first dollar medical expenses. So an individual has to himself pay the initial expenses that are called out-of-pocket costs.

In a number of HDHPs costs of immunization and preventive health care are excluded from the deductible which means that the individual is reimbursed for them. HDHPs can be taken both by individuals (self employed as well as employed) and employers. In 2008, HDHPs are being offered by insurance companies in America with deductibles ranging from a minimum of $1,100 for Self and $2,200 for Self and Family coverage. The maximum amount out-of-pocket limits for HDHPs is $5,600 for self and $11,200 for Self and Family enrollment. These deductible limits are called IRS limits as they are set by the Internal Revenue Service (IRS). In HDHPs the relation between the deductibles and the premium paid by the insured is inversely propotional i.e. higher the deductible, lower the premium and vice versa. The major purported advantages of HDHPs are that they will a) lower health care costs by causing patients to be more cost-conscious, and b) make insurance premiums more affordable for the uninsured. The logic is that when the patients are fully covered (i.e. have health plans with low deductibles), they tend to be less health conscious and also less cost conscious when going for treatment.

Opening a Health Savings Account

An individual can sign up for HSAs with banks, credit unions, insurance companies and other approved companies. However not all insurance companies offer HSAqualified health insurance plans so it is important to use an insurance company that offers this type of qualified insurance plan. The employer may also set up a plan for the employees. However, the account is always owned by the individual. Direct online enrollment in HSA-qualified health insurance is available in all states except Hawaii, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Vermont and Washington.

Contributions to the Health Savings Account

Contributions to HSAs can be made by an individual who owns the account, by an employer or by any other person. When made by the employer, the contribution is not included in the income of the employee. When made by an employee, it is treated as exempted from federal tax. For 2008, the maximum amount that can be contributed (and deducted) to an HSA from all sources is:
$2,900 (self-only coverage)
$5,800 (family coverage)

These limits are set by the U.S. Congress through statutes and they are indexed annually for inflation. For individuals above 55 years of age, there is a special catch up provision that allows them to deposit additional $800 for 2008 and $900 for 2009. The actual maximum amount an individual can contribute also depends on the number of months he is covered by an HDHP (pro-rated basis) as of the first day of a month. For eg If you have family HDHP coverage from January 1,2008 until June 30, 2008, then cease having HDHP coverage, you are allowed an HSA contribution of 6/12 of $5,800, or $2,900 for 2008. If you have family HDHP coverage from January 1,2008 until June 30, 2008, and have self-only HDHP coverage from July 1, 2008 to December 31, 2008, you are allowed an HSA contribution of 6/12 x $5,800 plus 6/12 of $2,900, or $4,350 for 2008. If an individual opens an HDHP on the first day of a month, then he can contribute to HSA on the first day itself. However, if he/she opens an account on any other day than the first, then he can contribute to the HSA from the next month onwards. Contributions can be made as late as April 15 of the following year. Contributions to the HSA in excess of the contribution limits must be withdrawn by the individual or be subject to an excise tax. The individual must pay income tax on the excess withdrawn amount.

Contributions by the Employer

The employer can make contributions to the employee’s HAS account under a salary reduction plan known as Section 125 plan. It is also called a cafeteria plan. The contributions made under the cafeteria plan are made on a pre-tax basis i.e. they are excluded from the employee’s income. The employer must make the contribution on a comparable basis. Comparable contributions are contributions to all HSAs of an employer which are 1) the same amount or 2) the same percentage of the annual deductible. However, part time employees who work for less than 30 hours a week can be treated separately. The employer can also categorize employees into those who opt for self coverage only and those who opt for a family coverage. The employer can automatically make contributions to the HSAs on the behalf of the employee unless the employee specifically chooses not to have such contributions by the employer.

Withdrawals from the HSAs

The HSA is owned by the employee and he/she can make qualified expenses from it whenever required. He/She also decides how much to contribute to it, how much to withdraw for qualified expenses, which company will hold the account and what type of investments will be made to grow the account. Another feature is that the funds remain in the account and role over from year to year. There are no use it or lose it rules. The HSA participants do not have to obtain advance approval from their HSA trustee or their medical insurer to withdraw funds, and the funds are not subject to income taxation if made for ‘qualified medical expenses’. Qualified medical expenses include costs for services and items covered by the health plan but subject to cost sharing such as a deductible and coinsurance, or co-payments, as well as many other expenses not covered under medical plans, such as dental, vision and chiropractic care; durable medical equipment such as eyeglasses and hearing aids; and transportation expenses related to medical care. Nonprescription, over-the-counter medications are also eligible. However, qualified medical expense must be incurred on or after the HSA was established.

Tax free distributions can be taken from the HSA for the qualified medical expenses of the person covered by the HDHP, the spouse (even if not covered) of the individual and any dependent (even if not covered) of the individual.12 The HSA account can also be used to pay previous year’s qualified expenses subject to the condition that those expenses were incurred after the HSA was set up. The individual must preserve the receipts for expenses met from the HSA as they may be needed to prove that the withdrawals from the HSA were made for qualified medical expenses and not otherwise used. Also the individual may have to produce the receipts before the insurance company to prove that the deductible limit was met. If a withdrawal is made for unqualified medical expenses, then the amount withdrawn is considered taxable (it is added to the individuals income) and is also subject to an additional 10 percent penalty. Normally the money also cannot be used for paying medical insurance premiums. However, in certain circumstances, exceptions are allowed.

These are –

1) to pay for any health plan coverage while receiving federal or state unemployment benefits.
2) COBRA continuation coverage after leaving employment with a company that offers health insurance coverage.
3) Qualified long-term care insurance.
4) Medicare premiums and out-of-pocket expenses, including deductibles, co-pays, and coinsurance for: Part A (hospital and inpatient services), Part B (physician and outpatient services), Part C (Medicare HMO and PPO plans) and Part D (prescription drugs).

However, if an individual dies, becomes disabled or reaches the age of 65, then withdrawals from the Health Savings Account are considered exempted from income tax and additional 10 percent penalty irrespective of the purpose for which those withdrawals are made. There are different methods through which funds can be withdrawn from the HSAs. Some HSAs provide account holders with debit cards, some with cheques and some have options for a reimbursement process similar to medical insurance.

Growth of HSAs

Ever since the Health Savings Accounts came into being in January 2004, there has been a phenomenal growth in their numbers. From around 1 million enrollees in March 2005, the number has grown to 6.1 million enrollees in January 2008.14 This represents an increase of 1.6 million since January 2007, 2.9 million since January 2006 and 5.1 million since March 2005. This growth has been visible across all segments. However, the growth in large groups and small groups has been much higher than in the individual category. According to the projections made by the U.S. Treasury Department, the number of HSA policy holders will increase to 14 million by 2010. These 14 million policies will provide cover to 25 to 30 million U.S. citizens.

In the Individual Market, 1.5 million people were covered by HSA/HDHPs purchased as on January 2008. Based on the number of covered lives, 27 percent of newly purchased individual policies (defined as those purchased during the most recent full month or quarter) were enrolled in HSA/HDHP coverage. In the small group market, enrollment stood at 1.8 million as of January 2008. In this group 31 percent of all new enrollments were in the HSA/HDHP category. The large group category had the largest enrollment with 2.8 million enrollees as of January 2008. In this category, six percent of all new enrollments were in the HSA/HDHP category.

Benefits of HSAs

The proponents of HSAs envisage a number of benefits from them. First and foremost it is believed that as they have a high deductible threshold, the insured will be more health conscious. Also they will be more cost conscious. The high deductibles will encourage people to be more careful about their health and health care expenses and will make them shop for bargains and be more vigilant against excesses in the health care industry. This, it is believed, will reduce the growing cost of health care and increase the efficiency of the health care system in the United States. HSA-eligible plans typically provide enrollee decision support tools that include, to some extent, information on the cost of health care services and the quality of health care providers. Experts suggest that reliable information about the cost of particular health care services and the quality of specific health care providers would help enrollees become more actively engaged in making health care purchasing decisions. These tools may be provided by health insurance carriers to all health insurance plan enrollees, but are likely to be more important to enrollees of HSA-eligible plans who have a greater financial incentive to make informed decisions about the quality and costs of health care providers and services.

It is believed that lower premiums associated with HSAs/HDHPs will enable more people to enroll for medical insurance. This will mean that lower income groups who do not have access to medicare will be able to open HSAs. No doubt higher deductibles are associated with HSA eligible HDHPs, but it is estimated that tax savings under HSAs and lower premiums will make them less expensive than other insurance plans. The funds put in the HSA can be rolled over from year to year. There are no use it or lose it rules. This leads to a growth in savings of the account holder. The funds can be accumulated tax free for future medical expenses if the holder so desires. Also the savings in the HSA can be grown through investments.

The nature of such investments is decided by the insured. The earnings on savings in the HSA are also exempt from income tax. The holder can withdraw his savings in the HSA after turning 65 years old without paying any taxes or penalties. The account holder has complete control over his/her account. He/She is the owner of the account right from its inception. A person can withdraw money as and when required without any gatekeeper. Also the owner decides how much to put in his/her account, how much to spend and how much to save for the future. The HSAs are portable in nature. This means that if the holder changes his/her job, becomes unemployed or moves to another location, he/she can still retain the account.

Also if the account holder so desires he can transfer his Health Saving Account from one managing agency to another. Thus portability is an advantage of HSAs. Another advantage is that most HSA plans provide first-dollar coverage for preventive care. This is true of virtually all HSA plans offered by large employers and over 95% of the plans offered by small employers. It was also true of over half (59%) of the plans which were purchased by individuals.

All of the plans offering first-dollar preventive care benefits included annual physicals, immunizations, well-baby and wellchild care, mammograms and Pap tests; 90% included prostate cancer screenings and 80% included colon cancer screenings. Some analysts believe that HSAs are more beneficial for the young and healthy as they do not have to pay frequent out of pocket costs. On the other hand, they have to pay lower premiums for HDHPs which help them meet unforeseen contingencies.

Health Savings Accounts are also advantageous for the employers. The benefits of choosing a health Savings Account over a traditional health insurance plan can directly affect the bottom line of an employer’s benefit budget. For instance Health Savings Accounts are dependent on a high deductible insurance policy, which lowers the premiums of the employee’s plan. Also all contributions to the Health Savings Account are pre-tax, thus lowering the gross payroll and reducing the amount of taxes the employer must pay.

Criticism of HSAs

The opponents of Health Savings Accounts contend that they would do more harm than good to America’s health insurance system. Some consumer organizations, such as Consumers Union, and many medical organizations, such as the American Public Health Association, have rejected HSAs because, in their opinion, they benefit only healthy, younger people and make the health care system more expensive for everyone else. According to Stanford economist Victor Fuchs, “The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance.

Some others believe that HSAs remove healthy people from the insurance pool and it makes premiums rise for everyone left. HSAs encourage people to look out for themselves more and spread the risk around less. Another concern is that the money people save in HSAs will be inadequate. Some people believe that HSAs do not allow for enough savings to cover costs. Even the person who contributes the maximum and never takes any money out would not be able to cover health care costs in retirement if inflation continues in the health care industry.

Opponents of HSAs, also include distinguished figures like state Insurance Commissioner John Garamendi, who called them a “dangerous prescription” that will destabilize the health insurance marketplace and make things even worse for the uninsured. Another criticism is that they benefit the rich more than the poor. Those who earn more will be able to get bigger tax breaks than those who earn less. Critics point out that higher deductibles along with insurance premiums will take away a large share of the earnings of the low income groups. Also lower income groups will not benefit
substantially from tax breaks as they are already paying little or no taxes. On the other hand tax breaks on savings in HSAs and on further income from those HSA savings will cost billions of dollars of tax money to the exchequer.

The Treasury Department has estimated HSAs would cost the government $156 billion over a decade. Critics say that this could rise substantially. Several surveys have been conducted regarding the efficacy of the HSAs and some have found that the account holders are not particularly satisfied with the HSA scheme and many are even ignorant about the working of the HSAs. One such survey conducted in 2007 of American employees by the human resources consulting firm Towers Perrin showed satisfaction with account based health plans (ABHPs) was low. People were not happy with them in general compared with people with more traditional health care. Respondants said they were not comfortable with the risk and did not understand how it works.

According to the Commonwealth Fund, early experience with HAS eligible high-deductible health plans reveals low satisfaction, high out of- pocket costs, and cost-related access problems. Another survey conducted with the Employee Benefits Research Institute found that people enrolled in HSA-eligible high-deductible health plans were much less satisfied with many aspects of their health care than adults in more comprehensive plans People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes. The survey also found that adults in high-deductible health plans are far more likely to delay or avoid getting needed care, or to skip medications, because of the cost. Problems are particularly pronounced among those with poorer health or lower incomes.

Political leaders have also been vocal about their criticism of the HSAs. Congressman John Conyers, Jr. issued the following statement criticizing the HSAs “The President’s health care plan is not about covering the uninsured, making health insurance affordable, or even driving down the cost of health care. Its real purpose is to make it easier for businesses to dump their health insurance burden onto workers, give tax breaks to the wealthy, and boost the profits of banks and financial brokers. The health care policies concocted at the behest of special interests do nothing to help the average American. In many cases, they can make health care even more inaccessible.” In fact a report of the U.S. governments Accountability office, published on April 1, 2008 says that the rate of enrollment in the HSAs is greater for higher income individuals than for lower income ones.

A study titled “Health Savings Accounts and High Deductible Health Plans: Are They an Option for Low-Income Families? By Catherine Hoffman and Jennifer Tolbert which was sponsored by the Kaiser Family Foundation reported the following key findings regarding the HSAs:

a) Premiums for HSA-qualified health plans may be lower than for traditional insurance, but these plans shift more of the financial risk to individuals and families through higher deductibles.
b) Premiums and out-of-pocket costs for HSA-qualified health plans would consume a substantial portion of a low-income family’s budget.
c) Most low-income individuals and families do not face high enough tax liability to benefit in a significant way from tax deductions associated with HSAs.
d) People with chronic conditions, disabilities, and others with high cost medical needs may face even greater out-of-pocket costs under HSA-qualified health plans.
e) Cost-sharing reduces the use of health care, especially primary and preventive services, and low-income individuals and those who are sicker are particularly sensitive to cost-sharing increases.
f) Health savings accounts and high deductible plans are unlikely to substantially increase health insurance coverage among the uninsured.

Choosing a Health Plan

Despite the advantages offered by the HSA, it may not be suitable for everyone. While choosing an insurance plan, an individual must consider the following factors:

1. The premiums to be paid.
2. Coverage/benefits available under the scheme.
3. Various exclusions and limitations.
4. Portability.
5. Out-of-pocket costs like coinsurance, co-pays, and deductibles.
6. Access to doctors, hospitals, and other providers.
7. How much and sometimes how one pays for care.
8. Any existing health issue or physical disability.
9. Type of tax savings available.

The plan you choose should according to your requirements and financial ability.

BIBLIOGRAPHY

1 Questions and Answers about Health Insurance- A Consumer Guide’ published jointly by the Agency for Healthcare Research and Quality (AHRQ)and America’s Health Insurance Plans (AHIP)
2 http://www.en.wikipedia.org/wiki/Health_savings_account
3 2002 AHIP Survey of Health Insurance Plans
4 “How High Is Too High? Implications of High-Deductible Health Plans” Davis, Karen; Michelle Doty and Alice Ho. The Commonwealth Fund, April 2005
5 http://www.fdhc.state.fl.us/schs/pdf/hsa_tri-fold_brochure.pdf
6 HSA/HDHP CENSUS 2008 by Hannah Yoo, Center for Policy and Research, America’s Health Insurance Plans
7″HEALTH SAVINGS ACCOUNTS Early Enrollee Experiences with Accounts and Eligible Health Plans” John E. Dicken Director, Health Care.
8 Thomas Wilder and Hannah Yoo, “A Survey of Preventive Benefits in Health Savings Account (HSA)Plans, July 2007,” America’s Health Insurance Plans, November 2007
9 Gladwell, Malcolm, “The Moral Hazard Myth”, The New Yorker (29-08-2005)
10 2008 Benchmark Survey HAS Bank
11. Employer Health Benefits 2007 Annual Survey, Kaiser Family Foundation
12. Health Savings Accounts and High Deductible Health Plans: Are They An Option for Low-Income Families?Catherine Hoffman and Jennifer Tolbert for Kaiser Family Foundation, October 2006
13. Medicare Prescription Drug, Improvement, and Modernization Act of 2003

All About Hemorrhoids – Their Treatment And Prevention

Hemorrhoids, also known as piles, are the dilatation, the stretching beyond normal dimensions of radicles of rectal veins inside the anal canal. In this instance a radicle is the smallest branch of a blood vein. Veins are weak compared to arteries due to their thin walls, therefore veins can become strained and twisted with any great back pressure. Veins have one-way valves to prevent back flow. The three rectal veins are named accordingly superior, middle and inferior rectal veins. Obstructions or pressure increase in these veins cause hemorrhoids.

Piles, or hemorrhoids, come in two types, internal and external. External hemorrhoids are outside the anus and are skin covered. Their color may be brown or black. Because nerves are so abundant in the anal area an external hemorrhoid is extremely painful.

The second type, internal hemorrhoids are in the interior of the anal canal, internal to the anus. They are purple or red and have a mucous membrane covering. They are usually painless. It isn’t unusual for a person to have both external and internal hemorrhoids at the same time.

Conditions that can lead hemorrhoids –

Hemorrhoids, a familial disease, tend to occur among members of a family, is sometimes blamed on heredity. The only animals that get hemorrhoids are those that stand on two legs. Most likely this is due to rectal vein congestion because of the pull of gravity. People who are chronically constipated often have piles problems. Resisting the urge to move your bowels at your body’s signal can bring about constipation and then hemorrhoids.

A high intake of meat, chicken, shrimp, spicy foods and more lead to hemorrhoids. The people least likely to get piles are those who have a high percentage of vegetables and fibrous food in their diet. Some women get hemorrhoids during pregnancy because of the uterus compressing the rectal veins. Rectal cancerous lesions might bring about hemorrhoids through obstructing blood flow.

Symptoms and indications of hemorrhoids –

With external hemorrhoids a protuberance can be seen and felt around the anus. There will be pain and discomfort in the anal area. While straining to expel a stool the pain will be worse.

Early on, internal hemorrhoids can’t be felt. Subsequently, in progression of the disease, the hemorrhoids will protrude as a stool is expelled and then retreat by themselves. When the condition worsens the protruded hemorrhoids won’t go back.

Bleeding isn’t unusual for either type hemorrhoid. However, when an internal hemorrhoid is retracted it could bleed internally, into the rectum. Bleeding occurs in splashes while pushing to expel a stool. In some cases the bleeding may be quite profuse. With both types of hemorrhoids there may be a mucus discharge and it will itch around the anus.

Other things brought about through hemorrhoids –

Hemorrhoids can become infected and the infection spreading to deeper veins and producing septicemia. Septicemia is blood poisoning caused by pathogenic microorganisms and their toxic products in the bloodstream.

Thrombosed hemorrhoids are not considered dangerous, however, they do cause considerable pain and swelling because they affect the nerve endings located in the anal skin. They’re first noticed as an acute extremely painful swelling at the anus. Thrombosis is the formation of a blood clot inside a blood vessel that obstructs the flow of blood. It occurs because of high pressure on the veins during excessive straining efforts. It’s rare to see thrombosis of an internal hemorrhoid.

Fibrosis usually follows thrombosis and is more common with external hemorrhoids than the internal type. Initially fibrosis is like a bump but with repeated friction of stool expulsion it will develop a stem like connecting part.

Suppuration is very rare and comes about because of infection of a thrombosed hemorrhoid. It’s accompanied by throbbing pain and swelling at the perianal region. An abscess with discharge of pus isn’t unusual.

Gangrene can develop when the tissues in the hemorrhoids and the adjoining skin die because of loss of blood supply. That occurs only when the arterial supply of the hemorrhoid is somehow or the other constricted.

Treatment of hemorrhoids –

Hemorrhoids are usually first treated based on the symptoms observed. Mild cases can be treated with over the counter medications, usually some type of cream or ointment. Moderately severe cases will respond to prescribed medications containing hydrocortisone acetate and pramoxine hydrochloride. Constipation should, of course be treated. If the medicines such as creams, ointments and foams are not producing results then the following treatments might be considered.

A thrombosed external hemorrhoid, one that has developed a blood clot, can be removed by cutting after administering local anaesthesia. The area is cut into using a scalpel and the clot is removed. There is nearly instant relief of the sharp pain. However, a dull ache may continue. Sitz baths, over-the-counter pain medications and the use of a rubber or air rubber donut may help with the pain.

Sclerosant injection can reduce hemorrhoid size. Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations. A medicine is injected into the vessels, which makes them shrink. This procedure is also used to treat varicose veins.

Rubber band ligation around the base of hemorrhoids is an useful outpatient treatment for second-degree internal hemorrhoids. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein which will cause it to lose its blood supply. The hemorrhoid will then shrivel and die within 2 to 7 days. The shriveled hemorrhoid and band will fall off during normal bowel movements.There may be some discomfort for a couple of days days after the procedure and a minor amount of bleeding may be experienced.

Cryosurgery has fallen out of favor as a treatment for hemorrhoids. The procedure consists of freezing and destroying internal or external hemorrhoids with a cryoprobe, which uses nitrous oxide or liquid nitrogen as freezing agents. The hemorrhoids are either directly frozen ligated first. In either case, local anaesthesia is usually used to deaden the pain.

Cryosurgery is more painful than other medical surgeries. And in addition, the patient will have an open wound for as long as a couple of weeks after surgery which can become infected. Moreover, patients can have an abnormal rectal discharge or foul odor which may require the use of absorbent pads.

Anal dilatation, or stretching of the anal canal, is no longer a method of choice for hemorrhoid treatment. The high incidence of fecal incontinence is, perhaps, the most objectionable side effect. Additionally, anal stretching can increase the rate of flatus incontinence. However, it may still be considered to help help younger women and en with overly tight sphincters who otherwise would have needed surgery. It may also helpful with strangulated and thrombosed prolapsed hemorrhoids.

Hemorrhoidectomy is the removal of hemorrhoids through surgery. It is done under general anesthesia and usually in a out patient surgery center. The surgery is performed with a scalpel, a tool that uses electricity (cautery pencil), or a laser. Hemorrhoidectomy is used primary only in severe cases for both internal and external hemorrhoids. It is significant post operative pain and usually it requires two to four weeks for recovery.

Prevention of hemorrhoids –

Diet and habits are the primary means of preventing hemorrhoids. Your diet should include plenty of of fruits and vegetables and fibrous food. Go easy on meats and shellfish. Eat when hungry, of course, but try to keep regular eating times. Make water your prime liquid intake, and drink plenty of it. Be regular in your bowel moveme
nts and do take something, food or medicine to treat constipation.

Medical Disclaimer –

I am not a health care professional. You must not rely on the information in this article as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information in this article.

If you think you may be suffering from hemorrhoids, or any of the symptoms described in this article or any other medical condition you should seek medical attention immediately. Never start a new exercise program without first consulting your doctor. The information provided in this article is intended solely for reference and based upon personal experiences. Individual results may vary and the information posted in this article should not be taken in place of proper medical treatment by a professional.

Economic Conditions Have Turned Off The Light

Due to current economic conditions the light at the end of the tunnel has been turned off…

I saw this posted at the end of an email I received today. I know it was meant to be funny, and I did laugh when I first read it. Then I couldn’t get the impact of the statement out of my head. It kept repeating like a song that gets stuck in your head.

I want to believe the glass is half full. As a person trying to live in the real world and on the internet, the very thought that there is no longer any light at the end of the tunnel is devastating.

Fortunately I surround myself with fantastic people who always believe in a better tomorrow. Small business entrepreneurs, they come from all walks of life and they all believe in the light.

One guy buys distressed homes in the nicer blue-collar parts in town, doing most of the contractor type work himself he fixes them up. A new coat of paint, kitchen floor and clean the carpet so he can make them available for rent at affordable rates. Investing his future in the housing market in these economic conditions is a very risky and long-term investment. But he believes the light at the end of the tunnel is on.

Another couple of business owners started their own niche bar and club, party style, tour business. They work to bring paying customers to not only the larger clubs in Las Vegas, but the smaller locals style mom and pop bars around town.

They lead by example. Not only do they have fun making money while having a rolling party, but they are actively bringing the stimulus through the doors the local businesses need.

And another guy, no longer working at a local Vegas club decided to build an online business he could pass to his son after his college graduation. I’m assuming that he’s going to need a good hearty income to pay off his college loans.

He chose the niche market of sports clothing. He’s not trying to run Nike out of business or take jobs away from Big-5 Sporting or even Wal-Mart. But he does believe that even in these economic times, if you have a dream your willing to combine it with hard work there will be a light at the end of the tunnel.

By surrounding myself with people who still believe in a brighter future. The people who will never except that economic conditions are so bad its time to turn the light off.

I can change that song in my head, change it to a song I learned as a child.

And with the current economic conditions, it’s needed more today than ever.

This little light of mine, I’m going to let it shine…

Join the Ranks of Famous Mountaineers for a Real Challenge

Mountaineering is a popular pastime for the very adventurous and healthy. Climbing and scaling mountains incrusted with snow and ice for days at a time is an extremely difficult task and those who attempt it must be in excellent health and condition. There have been many “famous” mountaineers over the years and some have made quite a name for themselves such as Sir Edmund Hillary a mountaineer from New Zealand. Hillary’s most famous climb was the ascent of Mount Everest in 1953. According to records, the first bona fide climber of tall mountains was someone who was named Ötzi the Iceman, whose mummified body was found in the Alps at an elevation of around 3000 metres and thought to have been there for at least 5300 years! His discovery has been the subject of much study and research since it was found in 1991.

Mountaineering is a sport for some and profession for others
Many consider mountain climbing a sport or challenging hobby while some take it very seriously and have even made a profession out of scaling tall mountains. They rise to the challenge to prove something to themselves or gain recognition, fame, and fortune. Sponsorship makes financial gain possible for those who work hard to maintain the strength and health it takes for this rigorous task. Rock, ice, snow, and extreme weather conditions make for a risky yet rewarding lifestyle for those who take up the challenge. Women have also become adventurous and prominent as a result of their mountaineering skills. Annabelle Bond, who was born in 1969, is one of four British women to have climbed Mount Everest (2004). She went on to become the fastest woman to scale that famous mountain.

Climbing is an addictive pastime that reaps big rewards
Edward Whymper (another Londoner) was the first explorer and climber to ascend the Matterhorn back in 1865. His claim to fame on that particular climb may have been that he survived! Four members of the group he was with perished during the ascent.

Aron Lee Ralston, born in Indianapolis, Indiana, USA in 1975 made himself renowned by having to cut his own arm off in order to be freed after falling and being stuck between rocks for five days, seven hours. His perilous climb is depicted in a movie titled 127 Hours.

Major William Bill Tilman is another well known English explorer and mountaineer noted for his climbing in the Himalayans as well as sailing voyages.

Matthias Zurbriggen, born in Geneva in 1856 climbed the Alps extensively as a mountain guide and alpinist. He climbed the Aconcagua which is the highest peak of the Americas. He has a New Zealand mountain peak named after him, the Zurbriggen Ridge.

Reccardo Cassin, born in Italy in 1909 made over 2500 ascents and considered one of the leading mountaineers of his time.

George Mallory, noted Englishman and mountaineer became obsessed with the conquest of Mount Everest back in the 1920’s and upon his death his explanation of why he did it “Because it is there” caused him to become famous throughout the world.

Maurice Herzog, a Frenchman, was the first man to scale a peak over 8000 metres (8091m above sea level). He lost his gloves and nearly his life after developing painful frostbite on the fingers of both hands as well as some toes. He and his fellow climbers did make it down successfully however.

The above climbers and many others risk their lives but continue on, thriving on the challenge.

Fix Your Smile With a Cosmetic Dentist

Have you taken the time to look at your teeth when you smile? Are you like most people, and don’t tend to notice anything is wrong until someone points it out to you? Even though it may a close friend or loved one that happens to make you notice that your teeth are not all that white or straight, don’t get upset because of their observation. Instead of running to the store and purchasing whitening strips and other devices that claim to give you the instant improvement you are searching for, visit your local cosmetic dentist instead.

There is no need for you to feel embarrassed or anxious about this visit. A cosmetic dentist handles cases like yours every day. When you go into their office and tell them why you are not happy with your smile, try to be as descriptive as possible. The more information you can provide them, the better they will be able to devise an appropriate plan of treatment. Keep in mind that depending on your personal complaints and hopes for your teeth, there may be several options for you to take advantage of.

A cosmetic dentist is a highly trained and skilled professional who is able to look at the goal you have in mind and show you how they can provide you with what works best for you to achieve similar results. Before any work is agreed upon or done, they will show you a computerized progression of what needs to be done to your teeth and gums. In some cases, you may need several months’ worth of work. This doesn’t mean that you shouldn’t have some sort of expectation for timeliness, but you should be aware that this process is not an instantaneous one.

Your cosmetic dentist wants to give you every reason in the world to smile. In order for them to do that, they have to be able to see and understand why you feel shy about doing so. It doesn’t matter if it is staining, broken or missing teeth, gaps, or other conditions that compromise the integrity of your smile– if you are not happy with the smile you were born with, this professional can make some modifications to change your feelings. As with any type of medical or dental procedure, before you start having any work done, you should take some time to learn about the risks that are associated with the type of procedure you are getting. This can help your cosmetic dentist choose a plan of treatment that will deliver the results you want without jeopardizing your health in the process.

Home Based Business Trends In A Fragile Economy

Home based businesses are many with some that are truly legitimate and others that are out to put a deep hole in your wallet. With today’s fragile economy, millions of people out of work and a shrinking middle class, there are those of us seeking ways to increase our financial means to make ends meet or to simply keep food on the table for our families. I’ve been a victim of the scams and have invested hundreds (if not thousands) of dollars seeking out the latest home business trend. But I have also learned a lot along the way and have acquired some tools to success that I would like to share with you to avoid any pitfalls you may experience in your search for the right opportunity.

#1. Product. You need to choose a product that literally most everyone needs. Think long and hard about this. Not everyone needs or likes healthy chocolate (I personally know someone who is allergic to it). The market is also flooded with many nutrition supplements claiming to be the next big trend. There is liquid form, pill form, shake form, juice form, etc. So which do you choose? Not to mention the expense and investment in such a venture. Don’t get me wrong. There are many fine health and wellness opportunities out there but they require a large financial commitment and again isn’t necessarily something most everyone wants or needs (we are in fact one of the most obese nations in the global market). Consider something such as cell phones. Nearly everyone has them everywhere you look and nearly everyone needs them. Even my 10 year old son is begging me to get him one since many of his friends already have them. The cell phone industry is exploding and more and more companies are popping up on the market.

#2. Affordability. As I mentioned earlier there are many legitimate home based business opportunities but they require a large financial commitment on your part and with a fragile economy this just isn’t an option. So along with the right product you need to have the right price. Opportunities that are too inexpensive (such as an opportunity for only $97) require hundreds of people in your downline just to make a few hundred dollars. Home based business opportunities that are too expensive are simply that-cost prohibitive and you don’t stand a chance at seeing a return (such as those opportunities that cost $1995-$3995). I’ve found that the latest legitimate home based business trends are priced between $300-$500. These are reasonably affordable even in a fragile economy and can get you up and running in no time. It will have you seeing a return on this investment within a few weeks to a few months.

#3. Team. I can’t stress enough how important it is to have a strong support system in place. Too often we are left to fend for ourselves after signing on with an opportunity and spend months trying to figure everything out ultimately ending in failure. A duplicatable, automated selling process, turn-key system that can run on auto pilot is vital to being successful with a home based business opportunity. These duplicatable systems can be achieved through websites and lead capture pages (which are generated by the company and given to each of their reps to build their business), DVDs explaining the opportunity and most importantly a way to market your business through offline methods (such as postcards and sales letters) in addition to online methods such as pay per clicks or cost per clicks. There are other online methods such as blogs, social media, articles and more but these systems are not easily duplicatable by everyone and requires a great deal of research, practice and trial and error to be successful with these methods. With the flood of online advertising, offline old-school mailbox methods such as postcards promoting an opportunity are becoming the trend among home based businesses.

#4. Leverage. The fourth and final point is leveraging a powerful system with the right opportunity that allows you to:

1. Make a lot of money

2. Make a lot of money quickly (and I don’t mean within 48 hours-let’s be reasonable here). You could with the right system be making money within a few weeks to a few months.

3. Be able to work from home only a few hours a week on a schedule that YOU decide

4. Have a business working for you even when you are not-translates to a 100% automated sales process from the moment your prospect sees your offer. This means:

-No personal selling
-No phone calls
-No hotel meetings
-No emails
-No sharing with friends and family

There is a lot to consider when seeking out the next home business trend. What I can tell you is from my experience, by using the tips I have mentioned as tools for researching and crafting a home business opportunity that’s right for you, it will greatly increase your chances for success.

How to Safely Remove Paint Transfer From a Vehicle Without Scratching

How To Properly Remove Paint Transfers From Your Automobile

It’s been staring you in the face now for weeks. Taunting you every time you walk past your car. Those unsightly red marks on your nice white bumper that just showed up one day when you went to the grocery store. No matter how hard you scrub when you wash your car they never seem to go away! Those red marks are referred to as paint transfers and by following these steps you can finally say, “Good Bye!”, to those unsightly blemishes.

Things You Will Need:

  1. Water Hose
  2. Water Hose Nozzle
  3. 5 Gallon Bucket
  4. Automotive Washing Soap
  5. Automotive Washing Brush
  6. Water Blade
  7. Drying Towels
  8. Automotive Clay Bar
  9. Automotive Clay Bar Lubricant
  10. Automotive Cutting Compound
  11. Automotive Cutting Compound Pads
  12. Automotive Detailing Polish
  13. Polish Pads
  14. Automotive Wax (A High Grade Acrylic Sealer Wax is Recommended)
  15. Automotive Wax Pads
  16. Microfiber Towels

STEP #1: Place enough automotive car wash soap to cover the bottom of your 5 gallon bucket and fill with water using your water hose and water hose nozzle.

STEP #2: Rinse your entire vehicle using the high pressure position on your water nozzle to rinse free any loose dirt from your vehicle.

STEP #3: Using your automotive wash brush and soap to clean your entire vehicle.

STEP #4: Rinse the vehicle clean of automotive soap.

STEP #5: Using your water blade, make long continuous strokes from top to bottom to remove water from the vehicle.

STEP #6: After the majority of the water from your vehicle has been removed with your water blade, use your drying towel to completely dry the exterior of your vehicle, paying close attention to seems and joints where water collects. NOTE: not completely drying your vehicle to hinder the following processes.

STEP #7: After your vehicle has been completely dried, spray the Automotive Clay Bar lubricant generously over the paint transfer area. Immediately after apply the lubricant gently take the automotive detailing clay and gently, using a back and forth motion paying close attention not to apply any undue pressure, rub the clay onto the paint. The automotive detailing clay removes any foreign particles that may have bonded to your paint. These particles can cause scratches and swirl marks during the compounding, polishing and waxing process if not removed. After you have completed the clay bar process use your microfiber to wipe the excess lubricant from the area.

STEP #8: Apply a small amount of automotive cutting compound to your compound pad and place onto the paint transfer area. Gently cover the entire paint transfer area with the cutting compound. After you have covered the paint transfer with cutting compound begin to make quick, circular motion with the cutting pad applying a generous amount of pressure. After the cutting compound has become semi translucent, buff off with your microfiber towel. NOTE: This process may need to be repeated if the paint transfer is still present.

STEP #9: Once the paint transfer has been removed apply a small amount of automotive detailing polish to your polish pad and with tight, circular motions apply to the compounded area until you can longer see the polish. Once you can longer see the polish buff the area with your microfiber towel.

STEP #10: After the automotive detail polish has been buffed clean, apply your wax to your wax pad and in tight, circular motions apply wax to the compounded and polished area. Once the wax has been applied and has turned to a white haze, buff the area with your microfiber pad until all the excess wax has been buffed clear.

NOTE: Generally during a professional detail the entire vehicle will have the automotive detail clay process applied to the vehicle as well as the waxing process.

The 9ff GTurbo 1200 With Custom Porsche Wheels

One of the most proficient Porsche models on the racetrack is the 911 GT3. It is designed specifically after the GT3 RSR race cars that Porsche uses in motorsports worldwide and is built to handle fast corners with ease. But the downfall of the 911 GT3 was that it wasn’t exactly a straight-line performance car, until the German car tuning specialists at 9ff transformed it with the GTrubo 1200. The new upgrade program gives the naturally-aspirated engine a powerful twin-turbocharger upgrade to go along with a modified chassis, new Porsche wheels, and a special exhaust.

The standard engine that comes in the 911 GT3 is a naturally-aspirated 3.8-liter that was designed after the racing engines used in the 911 GT3 RSRs sold by the German automaker. The high-revving flat-six cylinder engines were given a complete makeover thanks to 9ff with a new twin-turbocharger system that drastically increases output. The engine was bored out to 3.9 liters of displacement, reinforced with new steel pistons and rods, given upgraded camshafts and a new crankshaft, and fed with a new carbon fiber air box that fits onto a refinished intake manifold. A new exhaust system with sport catalytic converters, downpipes, mufflers, and quad tips helps to reduce backpressure and ensure that the turbochargers spool up quicker. After an ECU tune, the engine sends 1,200 horsepower at 8,100 RPM and 848 lb-ft. of torque at 5,800 RPM to each of the rear custom Porsche wheels. This blistering power output allows for the 9ff GTurbo 1200 to reach 62 mph in just 3.3 seconds, 124 mph in 7.1 seconds, and a top speed of 250 mph.

The power increase also necessitated that the chassis be upgraded. The transmission, driveshafts, and differential were all replaced with stronger units to handle 1,200 horsepower. The standard Porsche wheels were removed and new forged rims were installed with a center-locking mechanism similar to those used in race cars. In addition, new carbon ceramic brakes used in more powerful Porsche models were retrofitted to the 9ff GTurbo and a special Bilstein suspension was installed to allow for variable height, bound, and rebound settings. The finishing touch is a set of Continental Vmax tires fitted to the Porsche wheels that can handle the 200+ mph top speeds.

The cockpit of the new 9ff GTurbo 1200 features a more sport-oriented atmosphere. The two front seats were removed and replaced with special bucket seats that hold passengers in place better and are outfitted with alcantara. The dashboard, door panels, and center arm rest were each trimmed in a mix of leather and alcantara.

The new 9ff GTurbo upgrade conversion that includes the twin-turbocharged engine rebuild, new suspension, custom Porsche wheels, and unique interior design is currently available worldwide.

Payday Lenders – The History of Payday Loan and How it Effects Instant Approval – Part I

Here is how to avoid application disapproval and get instant cash credited into your account via payday loan. You can get up to $1500 dollars instantly without credit check, collateral or faxing of paper documents. All you need to get instant approval for cash advance is to know the nitty-gritty of payday loan and how it affects your loan application approval and disapproval.

Most people want to take advantage of payday service because they know that it is easy to access but they don’t know the disadvantages involved in payday services. Payday loan, no doubt it is the fastest kind of loan service that gives borrowers instant cash to meet their very urgent needs. But some people take payday loan for luxuries without knowing that payday package is for unavoidable needs especially those needs that can not wait till payday and it is also initiated to help people in emergency.

If you want to take advantage of payday facility, you have to count the cost before you apply. You have to understand that payday is a short term loan and its duration is usually between 15 to 31 days. Payday loan is a high interest loan because it is a non secured loan most time. Payday lenders most times do not require borrowers to present collateral or faxing of paper document and do not perform credit check to secure the lender. Because of the high risk payday lenders are exposed to, lender charge higher interest rate compare to other loan services. So if you want to take advantage of this loan service, you need to count the cost and make sure it is what you need before you apply.

What To Consider When Buying a Practice

The Price

It depends on what you’re buying. If all of the practice income is from personal services performed by the selling physician, the answer is generally “not a lot.” The price typically consists of (1) the value of the fixed assets (e.g. equipment, furniture), and (2) maybe a little more in order to avoid the cost of starting up a new practice from scratch. In the event, however, the practice also generates income from services that are not personally provided by the selling doctor, the price is increased to account for this “passive revenue.” How much? Maybe the amount of one year’s profit from that ancillary service.

Structure

Practice purchase take one of two forms: (1) stock purchase, or (2) asset purchase. Buyers that buy the stock of a medical practice are rare because the buyers get all the liabilities associated with the stock of the selling practice. Most practice purchases are asset purchases, which makes it easier to say what you’re buying, what you’re not buying, which liabilities you want to assume (e.g. leases) and which ones you don’t want to assume. Sellers often prefer stock purchases because the seller gets better tax treatment on the purchase price (capital gains instead of ordinary income) than sellers who sell just their assets.

Payment

There are two ways to pay for a practice: (1) on a pre-tax basis, or (2) on a post-tax basis. Employed physicians who become owners of a medical practice employer are often familiar with pre tax purchases because they have a portion of their salaries or bonuses applied to the purchase price, instead of getting the income, paying tax on it, then writing the seller a check. Sellers usually favor getting paid with the buyer’s after tax dollars, but often compromise and agree to accept at least a portion of the purchase price on a pre-tax basis via some sort of compensation offset.

Now that you know the big issues, you need to know how it’s done. The process generally involves the following:

1. Letter of intent;
2. Legal documents; and
3. Negotiating the documents.

Letter of Intent

Before people jump into a complex transaction (and pay lawyers lots of money), they usually like to “rough out” the deal points in a non binding document a few pages long which describes the guts of the transaction. In a medical practice LOI, those points are usually:

1. What is being sold (assets or stock);
2. Whether the accounts receivable are included or not-usually not;
3. The purchase price;
4. How it’s paid;
5. Whether the seller will stay on in the practice and if so, how he/she will be paid for working for the practice;
6. The restrictive covenants (e.g. noncompete) that will apply to the seller.

The Legal Documents

In an asset sale, the parties can expect: an asset purchase agreement; a promissory note (if payments will be made over a period of time); a security agreement (if there is a promissory note); a noncompetition agreement; and an employment agreement for the seller (if the seller will stay on). In a stock purchase, you will have a stock purchase agreement instead of an asset purchase agreement, plus a few other more minor documents.

The guts of the key transaction document are (1) the reps and warranties, and (2) the indemnification provisions. Reps and warranties are basically promises made by the seller about the practice. A buyer will wants loads and loads of them. indemnifications are essentially obligations of a seller to pay a buyer for harm that comes to the buyer which relate to the practice before the buyer bought it.

Noncompetes are often essential terms of a practice purchase. A buyer doesn’t want the seller hanging around soliciting patients or practicing across the street. Generally, the term runs two to five years and the geographic scope depends on the specialty and the market where the practice is located.

Negotiating the Documents

Very simple: everything is negotiable. Everything. That said, there are certain things the are usually set in stone. For instance, the buyer is gonna pay something over some period of time. The noncompete will apply for a period of time over a certain geographic area. Though a buyer will want a millions reps and warranties, they will probably be negotiated down. The indemnification provision may contain a “basket” and a “cap” so that the first dollar of damage may not be passed to the seller and the total amount may be limited. Though physicians may consider a practice sale or purchase to be a minor thing, they can be shocked at the complexity and intricacy of such issue as Medicare liability and recoupment issues. Moreover, even once the documents are negotiated, preparing all the disclosures and attachments to the documents is extremely time-consuming, whether the practice costs $1 or $10 Million. All the “i”s have to be dotted and the details attended to.

Conclusion

Practice purchases are a fact of life and will likely increase as the healthcare marketplace evolves. Agreeing on the core issues is important and just starts the ball rolling. Be prepared to engage a lawyer and accountant that have lots of experience doing these sorts of transactions.