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Dr. Ezekiel Emanuel wrote this article in the NY Times on January 3.

Among other things, Dr. Emanuel states  "A related intervention - an idea that never actually was in the Affordable Care Act but inspired the death panel accusation - is that physicians should be paid a one-time fee to talk with patients about their preferences for end-of-life care."

This is technically true.   However - this end-of-life “interventionâ€� WAS INCLUDED in HR3200 – the Bill that eventually was passed as the Affordable Care Act.  The end-of-life provision was removed from the final version of the Bill only because of widespread public outcry.

Dr. Emanuel knows this history full well and thus his statement above must be considered deliberately misleading.   Besides, Dr Emanuel is a long-time advocate of withholding care from some people in favor of other people.

More specifically, Section 1233 of HR3200 went on for 11 pages and 249 lines of text - remarkably long for a provision that its defenders claimed was innocuous.

Section 1233 of HR3200 would have compensated physicians for mandatory end-of-life counseling. It stated in detail exactly what physicians shall discuss, with whom, and at what times. Keep in mind Section 1233 was proposed legislation. Regulations are written after enactment and are always much more prescriptive than legislation.

So, was the objection to Section 1233 about compensating physicians?  Of course not.  People who objected to Section 1233 did not fear “physician compensationâ€�  - they feared a “death panelâ€�.  And why was that? The Affordable Care Act depends on a large reduction to Medicare spending.   Medicare patients fear that such a large reduction will end up harming them by making care less available.  Given that fear, mandatory end-of-life counseling was not seen as a means to bring out patients' "preferences" but rather as a tactic for the administration to reduce Medicare spending. 

That is, Medicare participants perceived a threat of withholding end of life care. This issue still has traction because neither the administration nor the Congress has ever, persuasively, answered the concerns raised about this threat.  By appearing evasive, the administration actually intensified the fears.

Those fears have not disappeared.  Dr. Emanuel also knows that full well.

.....is fair rates.

The brilliant minds at NAIC are concerned about adverse selection, as they should be.


"State insurance regulators remain concerned about “rate shockâ€� from the younger and healthier portion of the population leaving the health insurance marketplace and skewering it by taking the penalties in the first years when they are low."

 It won't be just the first years, at that rate of subsidy they are expecting the young to contribute they would need to triple the current tax for it to make sense for a young, healthy person to buy coverage. Before we toss young healthy males in with the 1% and blame them for everything that is wrong, though, let's look at their situation.

• Just out of High School or college and making entry level wages
• Auto Insurance is not community rated or age subsidized costing them many times what older drivers pay.
• Medicare and SS taxes already increased and sure to increase far more for the acturially excessive benefits seniors have already been promised.

In California, Aetna is proposing rate increases of as much as 22 percent, Anthem Blue Cross 26 percent and Blue Shield of California 20 percent for some of those policy holders, according to the insurers’ filings with the state for 2013. These rate requests are all the more striking after a 39 percent rise sought by Anthem Blue Cross in 2010 helped give impetus to the law, known as the Affordable Care Act, which was passed the same year and will not be fully in effect until 2014.

 In other states, like Florida and Ohio, insurers have been able to raise rates by at least 20 percent for some policy holders. The rate increases can amount to several hundred dollars a month.

In Reducing surgical complications: How to make it happen faster, I contrasted the way a hospital gets paid for rework with what happens in a manufacturing environment. In short: when a manufacturing process messes up a product the company doesn’t get paid at all, but when a hospital messes up it tends to get paid for the original flawed product and then paid agin to fix it.

I heard about an experience yesterday that makes the same point. A friend had a routine blood test in the morning at a hospital clinic. When results came back at the end of the work day there was an exceedingly high reading on the sodium level. The doctor who ordered the test called the patient to say he needed to go in to the emergency room to have it checked out, since the reading was higher than the doctor had ever seen for a patient and such a level could be life-threatening.

The patient went in, had a repeat test –which came back completely normal– and departed after paying the $150 co-pay. The attending physician in the emergency department referred to it as an iatrogenic event. No doubt the hospital will get paid in the low four figures for the visit, which wouldn’t have happened if the lab had done its job well the first time.

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Science is the belief in the ignorance of experts.

- Richard Feynman, The Pleasure of Finding Things Out

[...] CLASS wasn't going to be financially viable, and the first try just didn't work. But that doesn't mean we can just forget about it and move on. One way or another, long term care costs have to be addressed relatively soon. My prediction is that a new bill will be crafted in the next couple of years to create a solution similar to CLASS but hopefully with a more solid financial groundwork. But I think lawmakers might wait until 2014 - after the ACA has been more fully implemented and health insurance coverage is more widespread than it is today - to take action.

I asked Medecision’s Chief Medical Officer, Katherine Schneider, MD, MPhil, FAAFP to comment on key health care issues for 2013 including ACO formation, payer and provider consolidation, emerging innovations, and cost containment.

Here’s what she had to say:

1.  What can we expect from ACOs in the public sector in 2013? Will the private sector follow the public sector’s lead? What will be the key differences between Medicare ACOs and those serving commercial patients?

There is going to be a big ramping up period in January as many new ACOs are established under guidelines set by the Medicare Shared Savings Program. As with any new organization, there is going to be a learning curve for most of them.

U.S. health care is in the midst of an enormous transformation. As these changes are being made, industry players are faced with the constant challenge of not letting their business model get too far ahead of their care model, and vice versa. This is definitely the case for ACOs in their startup phase. Most of these ACOs have not dramatically changed their care model (if at all), and have put the business model first. There is nothing terribly wrong with taking this approach. If they had gone the opposite direction and had fully implemented a care model without the right business model in place, they could risk significant losses. For example, if an ACO acquired extra resources on the frontend to reduce hospital admissions on the backend, they could easily take a double hit by paying for these resources, and then also losing the hospital volume. The challenge most ACOs will experience is not letting the business model get too far ahead of the care model. ACOs need to realize that they have to start taking care of people differently if they are going to achieve any savings.

As to whether the private sector will follow the public sector’s lead, I think it is going to be decided market by market. Things will look differently market-by-market because all health care is local. Different payers and different delivery systems are at different points in this curve. Some markets are relatively advanced, and the public sector ACO may be the last to join the party. In other markets, it is the first to arrive.

The biggest difference between Medicare ACOs and those serving commercial patients is the ability to customize benefit design to support patient engagement, adherence, etc.

2.  Do you expect payers and providers to continue consolidating in 2013? If so, why?

Yes, absolutely. I think you are going to see three kinds of consolidation: between payer and payer, between delivery system and delivery system, and between payer and delivery system. The first two scenarios are mostly driven by economies of scale and leverage. Payers and delivery systems are both looking at some of the infrastructure investments and the capital required to succeed in this market. If you are small, it is going to be nearly impossible to keep up with the general market, and the definition of small has grown substantially in recent years. In 2013, I think we are going to see several medium and large plans and delivery systems consolidating.

The third scenario is consolidation between payer and delivery system. We are going to see more of that as well. It is going to be very interesting to see how integrated systems evolve under this scenario. In other words, as payers acquire delivery systems and delivery systems acquire payers are they going to meet in the middle, or are they going to be two different flavors? Right now, it is too early to tell. However, it is clear that both larger payers and larger delivery systems are understanding that they are going to be held more accountable for better outcomes at a lower cost and the only way to do that is to start to adopt some of the others’ capabilities. If you are a payer, you are going to have to better influence the hands-on care of your members and not just add resources as a workaround. If you are a delivery system, you are going to be held accountable for population health outcomes and are going to have to build many of the capabilities that have been traditionally managed by health plan, like population health management, data systems, and care management tools.

As the payer and delivery systems start to merge and collaborate more, it is really important for us to go beyond just changing the sign on the door and transferring health plan functions into a delivery system. The real opportunity we have before us – and this is really the challenge for our industry – is how can we get more value out of these collaborations and not just create new layers and redundancies. The organizations that successfully navigate this transformation are going to emerge as the true market differentiators and winners.

3.  Despite the consolidation, is there room for start-up organizations, too, such as the COOP plans? 

As I mentioned above, it is very expensive to play in this market, and the cost of entry is only going up. There is definitely room for start-up organizations. However, if you are going to try to be a start-up organization in this space, it probably needs to be in some kind of a disruptive model in order to be successful. There is a lot of opportunity for startups that are willing to use their small size and agility to their advantage and adopt a different model from the start. It is much easier to innovate and go in a new direction when you are a small speedboat (as opposed to a large tanker).

4.  Are there specific innovations you think will have an impact in the near term?

I think we are going to start seeing much wider adoption of consumer engagement tools and technology. While some of them will fail, I believe that some will make a significant impact, particularly in niche areas. I strongly believe that benefit design offers much potential as well. Also, there are many things that can be done to move the needle around behaviors, such as preventive care, lifestyle change, etc.

I am also interested in big data innovations, and what we can glean from big data that is actionable and not just interesting. For example, something as simple as hypertension can be easily tracked using a few pieces of data – primarily blood pressure readings. There is a huge room for improvement in managing our population’s long-term health with this information. It is a huge cost driver.

5.  Where is cost containment going? Will we see anything new in 2013?

We are going to see some old practices reemerging in 2013. The drive to get to a zero premium plan on the health insurance exchanges is going to, for better or worse, go back to the blunt instrument of unit price and narrow networks that are selected based upon lowest unit price. From the government side – with the fiscal cliff, the debt ceiling and SGR all hitting at once – you are definitely going to see price pressure on government programs.

On the innovation side, I hope we see some innovation around system transformation that focuses more on total cost of care than just ratcheting down unit price. In other words, we need to focus on achieving better outcomes at a lower overall cost, not just driving unit costs down. Unfortunately, ratcheting down unit cost is much easier than trying to transform systems of care and systems of payment.

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Brad Wright of Wright on Health hosts this week’s New Year’s themed-edition of the Health Wonk Review.

President Barack Obama has signed the American Taxpayer Relief Act of 2012, which continues current Medicare payment rates for the nation’s physicians through Dec. 31, 2013. This bill nullifies the Sustainable Growth Rate which, if implemented, would have reduced Medicare payments to physicians by 26.5 percent.  The doc fix will cost $10.6 billion in fiscal year 2013.  This same issue appears every December year after year.  Reason Magazine notes that this is just another example that Congress is not able to stick to promises to cut spending in the future.

According to Health System Review, “The new legislation also halts sequestration for two months to prevent a 2 percent spending cut for all Medicare providers, extends the Medicare 1.0 RVU GPCI floor through December 31, extends the Medicare therapy cap exception process through the end of the year and increases the Medicare therapy service multiple procedure payment reduction to 50 percent effective April 1.”  (for more detail, see a DoctorsManagement report).

From the list above, you can see that physicians also won another battle by keeping the GPCI work floor set to a minimum of 1.0. The work GPCI adjusts physician payments based on geographic variation in physician wages. Thus, all physicians in low-wage areas will now receive the same reimbursement for work RVUs as the national average physician.

If doctors won, then who lost?  The answer is hospitals.

WSJ’s Washington Wire reports that “Several pieces of the bill, which is headed for President Barack Obama’s desk, would reduce federal payments to hospitals in exchange for staving off cuts to doctor’s pay. Hospitals are calling it a raid on their funding, which has already been subject to cuts in the health overhaul law.”

Specifically, KFF reports how Medicare reimbursement to hospitals would decrease.

First, it would cut $10.5 billion from projected Medicare hospital payments over 10 years for inpatient or overnight care through a downward adjustment in annual base payment increases.  The Senate measure also would reduce Medicaid disproportionate share payments to hospitals by an additional $4.2 billion over the next decade.   These cuts are on top of those made to hospitals as part of the 2010 health care law.

Analysis by Nguyen and Sheingold stated that the DSH adjustment as was implemented by the ACA seemed reasonable, but payments for medical residents (IME) are too high.  Nevertheless, this bill further reduces DSH payments.  This cut may be reasonable, however, since the number of individuals without insurance will likely fall due to the ACA.

The CBO evaluates the fiscal impact of the American Taxpayer Relief Act and finds that the deficit would increase by almost 4 trillion dollars over the next 10 years.

Wright on Health hosts the first Health Wonk Review of what we all hope will turn out the be a happy, healthy and lucky 2013.

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That is the conclusion of this study. More information below:

Background

The ARRA stimulus package included $2.2 billion for health care cost-effectiveness research focusing on chronic disease prevention and disease management initiatives. These programs aim to address increasing health care costs for a number of diseases, such as: cancer, diabetes, heart disease, obesity, and smoking-related illnesses. The disease management initiatives hope to improve health outcomes and reduce the costs that occur due to acute aggravations or worsening symptoms by aligning patient care with the evidence base.

State Implementation and Identification Strategy

Washington, Texas, and Georgia have implemented diabetic disease management programs. The authors use a difference in difference strategy to measure whether costs and number of emergency admissions for Washington, Texas, and Georgia decreased relative to states that did not implement diabetic disease management programs. Washington implemented its disease managment program in 2002, Texas in 2004, and Georgia in 2005. The authors use the National InPatient Sample (NIS) data from the Health Care Cost and Utilization Project (HCUP) between the years 2000-2008.

Results

The authors found no effect. The following three graphs display this results graphically.

Additional regression analysis finds that reform did not create statistically significant decreases in either in emergency admissions or inpatient charges.  The regression models controlled for state and year effects with dummy variables as well as median state income, state obesity rate, and state Medicaid enrollment to isolate the effects of the disease management programs on the two outcome variables.

Thus, the authors conclude that “This study finds that the disease management programs enacted in Washington, Texas, and Georgia were not effective at controlling inpatient diabetic costs or reducing emergency department admissions.”

Source

• Conti, M. S. (2012), Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs. Health Services Research. doi: 10.1111/1475-6773.12024

American Well is a pioneering telehealth company. Four years ago, when the company was just launching its first commercial deployments, I interviewed CEO Dr. Roy Schoenberg. Recently I interviewed him again and asked for his views on the progress of telehealth since 2008, impact of the Affordable Care Act, how physicians and health plans are reacting to American Well, and what it all means for patients. He also contrasted the US market with Australia and New Zealand, the first permanent overseas markets for the company.

The audio for this podcast can be accessed here.

David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with Dr. Roy Schoenberg. He is CEO of American Well. Roy, thanks for joining me today.

Dr. Roy Schoenberg: Thank you, David. Good morning.

Williams: It’s been a few years since we last caught up. Can you describe what progress you’ve made since we last spoke?

Schoenberg: A lot has happened in the health care industry. Everybody’s looking at the political arena where the health care industry is seeing a tremendous transformation.  Other dimensions of health care including the recent embrace of technology and the changing ways in which health care is delivered have also set the stage. We have so many issues including access, supply of physicians, reimbursement, and the way people are getting their health care benefits.

We have seen significant change in the way that people along the entire spectrum of this industry are looking at how technology can be used to actually acquire health care services. This has been led by the biggest stakeholders in the health care business, which are the health insurance companies. Over the last couple of years they have taken the lead in changing health care delivery.

There are a lot of different things that we can do to let patients know what they need to do for themselves and how to get more involved in preventive care. Along the same lines is the understanding that we don’t have enough health care services available in many parts of the country and that using ubiquitous technologies like the Internet in order to disseminate and redistribute is going to have a significant impact.

We have been at the right place at the right time and as you could imagine that has had a tremendous transformative impact on our business itself.

Williams: Could you comment on what has happened from the federal government level, and what impact you see from the HITECH part of the stimulus and also from the Affordable Care Act?

Schoenberg: With the Affordable Care Act you’re going to have anywhere between 34 to 36 million people who have been underinsured or non-insured now having proper access to the health care system.   That is happy news for a lot of people but the reality is that the supply part of the health care system hasn’t really significantly changed and it’s already been very strained.

As a result of that even the federal government, which usually takes longer than private commercial industry, has taken seriously the notion that we need to fundamentally change how we perceive supply and demand. One of the things that we have seen in the last couple of years in a variety of areas is new opinions by the movers and shakers of Washington, but also from the legislators at the state and the local level. They are saying, ‘We need to revisit the notion of the use of technology.’

This became most prominent starting in the last year from legislation that was passed in a variety of different states –I believe 16 to date.  It says explicitly that telehealth needs to be a reimbursable form of care delivery. State medical boards have literally had a 180-degree change in the way they see the validity of telehealth and telemedicine as a conduit for care delivery.

More and more opinion papers coming out of Washington both by legislators as well as by regulators are talking about the fact that it has now become imperative for us to enlist technology.

We are seeing increasingly that many people are thinking of telehealth and telemedicine as such a transformative tool. There is a lively discussion around what the regulations should be and how we can make sure that the use of this technology is going to be on the safe side of care delivery rather than on how the Internet has traditionally been abused by Internet pharmacies or for those kinds of interventions that are absolutely inappropriate.

We’re seeing a flurry of embrace at a variety of levels. Some of it is inquisitive; some of it is very decisive. We are seeing that the industry from top to bottom has decided to move forward on the use of these technologies.

Williams: Let’s talk a little more about access. You’re describing having another 35 million or so people in the system placing demands on providers and the use of technology to work on expanding supply. If we look at the example of electronic medical records, one could make the argument that use of that technology actually decreases supply because it reduces the available capacity of some providers as they adopt it. How is it that telehealth has a different and better effect?

Schoenberg: I want to make a distinction between two terms because people usually think of telemedicine and telehealth as the same thing. Telemedicine has been around for about 20 years. It is used to connect physicians across geographies in order to deliver care for patients.

In a rural area a patient can use telemedicine to see an oncologist that comes from a highly reputable tertiary medical center in an urban area. That in itself creates efficiency, but it does not increase the supply of medical services. It just allows consultation and immediate care to happen more readily.

Telehealth on the other hand is the use of technologies to bring health care services and available physicians into the hands of patients wherever those patients are.  Patients can directly tap into the telehealth system, find an available physician and connect with them. What that means is that we have physicians out there that have the opportunity to be in front of a patient right now as we’re having this interview.

There are numerous physicians that are not in front of a patient right now even though they could be, whether it’s because of cancellations, because they live in a specific place, or because they don’t want to practice five days a week. Increasingly many physicians are lessening their clinical hours, maybe because they are young mothers, or they are physicians who are on the retirement path. In any one of those cases technology allows us to tap into those physicians and say, “If you have an hour right now, we can actually use that time from your home to care for patients that need to see you.â€� What that means and what we have seen across the board is that we have the ability to bring back into the grid many of those lost opportunities and literally put them in front of patients that need to be seen.

Now we need to think about telehealth also as a way not only to overcome geographies, but also to overcome other barriers of access. It’s not only in the islands of Hawaii, or rural North Dakota, or Upstate New York.

Many patients live in metropolitan areas, but they are elderly patients, they have many different medical conditions that make it very difficult for them to leave their home. Usually these patients fall off the grid because they don’t get followed up. They don’t show up as needed in front of the different physicians.

We can use telehealth rather than force them to show up at the gates of health care. We can use telehealth to bring health care to them. That is another example of how access to health care has remarkably changed just by the fact that technology can extend the health care system into where the patients are.

These are just two examples. But as you said, electronic medical records  –which are absolutely necessary to change the accountability of care that’s being delivered– don’t really change the availability of the service themselves.

Telehealth on the flip side is truly redistributing the available supply and sometimes the supply that went off the grid and making it available to patients. That’s why it is perceived as such a radical change and a radical improvement in the availability of the entire system to its end consumers who are the patients.

Williams: Since the last time we spoke, there have been some other services that have sprung up that are going at the same problem in a different way. For example, ZocDoc allows physicians to increase their income and improve their mix. What’s the connection between what ZocDoc is doing and what you’re doing if any?

Schoenberg: In a way ZocDoc, the older kind of minute clinic and what we do are really different solutions for the same issue. Patients are struggling to get a hold of health care professionals to get care and we all help to fill that need.

What ZocDoc is doing is pretty remarkable. They say, we know that there are cancelled appointments, we know that there are holes in the schedule of physicians and we want to make sure that if there are people around in that physician office or in that geography that need to get in front of a doctor, we’re going to bring that opportunity to their attention.

What ZocDoc is doing is facilitating filling up a physician’s calendar where there are options for seeing patients.  It brokers those open appointments to patients over the web and they have done a terrific job in every way. I think physicians are very happy with it and patients are very happy with it.

That helps if you live in a place where there is a physician with an open appointment. Unfortunately in many of the cases, it’s not the physician you need, you need to see a specialist, or you live too far, or you have difficulty coming out of your house or traveling, or a variety of different issues. You therefore cannot wait for an appointment that’s going to happen in three days even if it’s from ZocDoc.

While they are brokering opportunities of in-person encounters, we’re using technology to allow you to see the physician from wherever you are. It’s different solutions for the same issue and realistically they complementary offerings.

Williams: When we spoke last time, you were starting your first major implementation in Hawaii. Now I imagine you’re looking out the next five or ten years. I’m wondering how you see the market for telehealth as you’ve defined it and in particular do you have a sense of how larger the opportunity is for the telehealth market in the United States?

Schoenberg:  We’re very careful not to make prophecies about where telehealth is going to be. But one thing that we can do is extrapolate from the change in our business that happened over the last couple of years. Five years ago we started as the crazy people who proposed that health care could be delivered meaningfully through technology in the state of Hawaii, a state that suffers from major geographical barriers for the delivery of care.

Today we’re looking at our client pool, the biggest health plans in the country, the federal government, national pharmacy chains, large behavioral health systems, very large employer groups and these have diversified so rapidly. Some people will not have the appreciation for how slow the traditional health care system moves. This industry, which is in every way a health care industry derivative, has moved at the pace of consumer technology. That is an incredible difference from any other thing that we’ve seen in health care.

Not only are different people using telehealth and enjoying it, but the people that govern the money flows are increasingly getting to the point of saying, ‘Well, this needs to be part of regular health care.â€� Usually the people that drive that would be the insurance companies that govern most of the dollars flowing in the health care system, and they are saying at this time, ‘We are going to incorporate telehealth increasingly as a part of our plan of benefit product.’

What that means is that down the line, telehealth will become part of your medicine cabinet. When you are at home and you have a health care issue, the first point of entry into the health care system will be right there where you are. You will be able to walk and use your iPad or you iPhone or your browser in order to tap into the health care system and begin to understand how you should acquire services.

It is clear that not everything you need is going to be delivered to you through telehealth. Clearly if you need surgery or if you need an injection, or whatever it is, that’s not going to happen through a browser, but I believe what we will see rapidly is that health care will be available to us at our home through this technology. It will then either solve all of our issues or advise us about what would be the prudent next step of acquiring a physician from a system that usually tends to be painful to interact with and often costly.

Williams: One topic that has gained some momentum since we last spoke is physician quality and patient experience. There has been some more published information about what the quality is of various physicians or physician groups. There is an increasing interest in how traditional care settings compare with less traditional mechanisms of delivering care including minute clinics, or onsite clinics. Has American Well done anything to make a comparison of its services with those that are offered in more traditional ways?

Schoenberg: It’s difficult to compare the scope of services that you deliver through telehealth versus the ones that you deliver in person.

Nobody is looking to reinvent health care. The relationship that we have with doctors and the trust that we have with doctors is fundamental for our ability to receive good care and to follow up in the instructions that we receive in order to care for the issues that we have.

Understanding that we need to preserve those things rather than introduce alternatives to them has been at the foundation of the technologies that we brought into the market. First of all we want to make sure that your interaction with a physician is going to be intimate.

We do not believe that an exchange of an email with Dr. Joe Schmo is a clinical encounter. We even don’t believe that telephone interaction with a physician is sufficient. For the most part you need to have a full intimate interaction, seeing and talking to the physician.

The second thing is that the health care professionals you interact with cannot be the people you don’t know. When we deploy our systems, we’re using them to connect patients with physicians that were otherwise made available to them by their insurance company.

If you forget technology, when you need to see a physician, you go into the directory of whatever health plan that you belong to. That’s how you find the list of physicians that have been checked and credentialed, followed for quality of care, licensed properly and board certified.

What technology should do rather than say, “Well, there is a pool of unknown Dr. Joe Schmo’s who say they are physicians and you’re going to get to them through the Internet,â€� is to make sure that the people you interact with are going to be the same people that you would otherwise schedule appointments with.

The level of accountability for the care that’s being delivered over technology shouldn’t be any different than the level of accountability that happens when you are seeing someone in person. The information presented to physicians before they see you has to be complete and exhaustive. They need to understand the rest of your medical record before they start treating you because that’s very important to direct their care.

We need to make sure that the care that they give you is properly documented so that they feel accountable. We want to make sure that the care that they deliver to you is going to be known to the next physician that you’re going to be seen by in order to preserve something called continuity of care, which is remarkably important for quality, but also for the efficiency of the system.

This also cannot be a gadget-type intervention that you find over the web. It has to be tied to the way that you get health care services. It means it has to be tied to your insurance product. You need to pay a co-pay for it like you do when you see a doctor. It needs to be introduced to you and explained to you by the same people who tell you how you can acquire medical services. The only way to make sure that the quality of service that you get over telehealth is good enough is to make sure that telehealth is an extension of your traditional health care system rather than a new alternative.

Williams: It was interesting to see that your first deployment outside of the US was in Australia and New Zealand. Could you comment about why that region of the world was first and what’s different there compared to what we see here in the United States?

Schoenberg: The first time we deployed the system outside of the US was actually for a period of time during the earthquake in Haiti. We allowed physicians from a top medical center in Boston to be available through the system to the medical personnel on the ground there who needed help performing field surgery and everything else. That was really the first time we crossed the border of the United States. But from commercial deployment standpoint, you’re absolutely right.

Australia is our largest overseas deployment. It’s the same in the sense that Australia is not unlike Hawaii in many areas. They have a lot of rural geographies involved.

There is a really desperate need for distribution of medical services. There are many areas where patients have to literally take a plane and fly for hours before they see the right kind of health care professional or even any kind of health care professional.

In that sense using technology that makes access to downtown Melbourne the same as it is in Central Australia has been on the mind of regulators and the government, and everybody else there.

The other dimension that is very interesting is that they have fast forwarded the thinking that we’re seeing here in Washington in 2012 to the point that the government has already embraced very far reaching rules about how imperative it is for the country as a whole to embrace these technologies.

The government has stated in a variety of different ways and in different kinds of domains that reimbursement for physicians for seeing a patient through technology should not be any different than reimbursing a physician for seeing the patient in person. It’s just that maybe the technology is the only way in which this patient can see the physician, and since the physician has to deliver the best care they have through the limitations of technology, they’re not doing anything less than seeing the patient in person.

One thing that is unique about Australia is that they are the best example of a national agenda for embracing telehealth that we’ve seen anywhere. We were fortunate to be the ones picked by the people that run telehealth in Australia to actually realize that. Interestingly enough, we do see that happening in other parts of the world, not necessarily just in places that have geographical issues. The United Kingdom is embracing similar rules in order to revamp their National Health Service.

Other countries are following suit, and I think luckily we are at the point that Washington is picking up on it. We’re going to see that remarkable change happen right in front of our eyes in 2013.  I’m happy to go on record in saying that is going to be a transformational year for the health care industry because of the use of telehealth.

Williams: I’ve been speaking today with Dr. Roy Schoenberg, CEO of American Well. Roy thanks so much for your time.

Schoenberg: Thank you so much, David.

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Senator Aguilar’s plan for universal healthcare in Colorado is based on a genuine need: even with current and planned state and federal healthcare reforms, there will still be a lot people in Colorado without health insurance. The CBO estimates that on a national level, we’ll have 30 million uninsured people in the US a decade from now. That’s taking into account the fact that SCOTUS struck down a provision in the ACA that would have required states to expand their Medicaid programs. States have flexibility with that now, and some will likely choose not to expand. Colorado, however, is expected to expand its Medicaid program (not surprising, given how much work the state has already done on that front). The uninsured population in Colorado hovers somewhere in the 600,000+ range, depending on how and when the samples are studied. If the ACA is expected to reduce the national uninsured population from 53 million to 30 million, and taking into account the fact that Colorado will likely be one of the states that opts for Medicaid expansion, I would say it’s reasonable to expect that the uninsured population here will be reduced by at least 50% once the ACA is fully implemented. But that still potentially leaves a few hundred thousand people – not an insignificant number by any stretch – with no health insurance. Those are the people Senator Aguilar is trying to help.

There are many ways that Medicare evaluates hospital quality. Medicare conducts patient surveys (i.e,. HCAHPS). Medicare has hospitals report a variety of process of care measures through the Inpatient Quality Report (IQR) Program. Medicare uses data that Centers for Disease Control and Prevention (CDC) collects via the National Healthcare Safety Network (NHSN) tool to measure hospital-acquired infection (HAI) rates.

In addition to these initiatives, there are five main ways that Medicare evaluates hospital quality using claims data: (i) AHRQ patient safety and inpatient quality indicators; (ii) hospital acquired conditions, (iii) mortality, (iv) readmissions, and (v) spending per beneficiary. A list of the quality measures that fall under each category are listed below.

AHRQ Measures

• PSI 04 – Death among surgical inpatients with serious treatable complications
• PSI 06 – Iatrogenic pneumothorax
• PSI 11 – Postoperative respiratory failure
• PSI 12 – Postoperative pulmonary embolism or deep vein thrombosis
• PSI 14 – Postoperative wound dehiscence
• PSI 15 – Accidental puncture or laceration
• PSI 90 composite – Patient safety for selected indicators
• IQI 11 – Abdominal aortic aneurysm (AAA) repair mortality
• IQI 19 – Hip fracture mortality
• IQI 91 composite – Mortality for selected conditions

For more information see QualityNet or the AHRQ website.

Hospital Acquired Conditions

1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Pressure ulcer stages III and IV
5. Falls and trauma, including: Fractures, Dislocations, Intracranial injuries, Crushing injuries, Burns, Other injuries
6. Vascular catheter-associated infection
7. Catheter-associated urinary tract infection
8. Manifestations of poor glycemic control, including: diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity

There is one more complication CMS added: Complication Rate Following Elective Primary THA and/or TKA.

For more information see QualityNET HACs.

Mortality

• 30-day mortality measures for Acute Myocardial Infarction
• 30-day mortality measures for Heart Failure
• 30-day mortality measures for Heart Failure Pneumonia

Readmissions

• All-cause 30-day readmissions for acute myocardial infarction (AMI),
• All-cause 30-day readmissions for heart failure (HF),
• All-cause 30-day readmissions for pneumonia (PN)
• Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)
• 30-Day All-Cause Risk-Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Spending

• Medicare Spending per Beneficiary (MSPB) - assesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during a spending-per-beneficiary episode that spans from three days prior to an inpatient hospital admission through 30 days after discharge.

[...] it may not be what you'd guess. The study he references looked at inpatient costs from 2001 to 2006 (admittedly a bit out of date now, but still relevant and interesting data) and found that the biggest increases were in "supplies and devices", ICU, and hospital room and board - all three of those areas had double digit percentage increases in costs from 2001 to 2006. I would be very curious to see another column on that chart with 2012 numbers and the corresponding percentage increases... are those three areas still the culprits, or have others (like pharmacy?) surpassed them?

Check out the Surviving the Mayan Apocalypse edition of the Cavalcade of Risk blog carnival.

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[...] very clearly how we could save $20 billion per year if the feds could negotiate drug prices with pharmaceutical manufacturers. That's forbidden by the language of the original legislation that created Medicare Part D (I know, it's ridiculous, but that's how it is), so it would require some legislation at this point to change things. Nobody in power seems to want to address this issue, probably because pharmaceutical companies make such large campaign contributions. But as I've pointed out several times, they also earn huge profits (far more than any health insurance company, although health insurance companies are the ones that are repeatedly targeted by the media as having excessive profits). Maybe it's time for a change.[...]

[...] Is it fair to say that health insurance carriers shouldn't be able to use genetic testing information during underwriting, but that they should have to pay for preventive healthcare that results from genetic testing? I don't think there's an easy answer there. It's hard to put a price tag on health and life, and it's difficult to say that a person who is making such a hard decision should also be faced with a potentially very large medical bill at the same time. But if we're going to categorically state that genetic testing cannot be used to the advantage of health insurance carriers, it's hard to turn around and say that the carriers should also be required to pay for treatment that comes about as a result of that same testing. What do you think? As technology moves forward, I have no doubt that genetic testing will become more routine, and various preventive measures based on those tests will likely become fairly commonplace. If they become a larger part of our general healthcare process, I would say that it's reasonable to assume they will also be covered more frequently by health insurance carriers. And as of 2014, some of the issues addressed by GINA will become moot points too, as health insurance will all be guaranteed issue. So this is a subject that might just work itself out naturally over the next decade or so. But for now, it does leave plenty of room for debate.

Increasingly, patients are bearing a greater and greater portion of their healthcare costs -- whether that be in the form of a higher deductible where they're paying the first several thousand dollars a year of their healthcare expenses or with larger co-pays and higher premiums or simply because they have chosen not get insurance because it's too expensive and they're paying in cash.

Some of the biggest frustrations on the patient end have to do with the difficulty of seeing what you'll be paying until well after the service is rendered, making it very difficult to be able to compare quality and prices to find better value.  And the savings can be HUGE!  Prices can vary as much as 70-80% for the EXACT same service or test.  In today's economy, saving 70-80% on a test that could costs thousands of dollars makes a huge impact on the patient's pocketbook. 

SnapHealth, founded by two ER doctors, is breaking out of the model by offering patients up-front pricing and the ability to compare based on customer service reviews and credentials. Using a familiar web-based interface as you would use to shop for hotels or airplane tickets, patients can quickly and easily purchase the healthcare services they need at significant discounts and know prices upfront.

Doctors and testing facilities can offer these discounts knowing that they won't be refused payment by insurance companies or the government, and that they won't have to pay a billing company to chase after payment.

Launched in Houston, TX, SnapHealth will be opening in several other markets soon.

Take control of your healthcare and your pocketbook today!  After all, it's your health and your money.

David Wong, MD, CEO Snaphealth

We're updating the Health Blog infrequently. Please consider bookmarking the Journal's Health and Wellness page, for daily updates on health news and analysis.

There is a really big question in health care, one that could shift the entire industry toward more patient-focused care while simultaneously driving down health care costs. Very few people even think about this question. In my experience even fewer, if any, of those who do ask it are involved in developing health care policy at the federal or state level.

This one question, if deployed, would start to solve the issues facing patients, clinicians, payers, and hospitals – everyone involved in getting or receiving medical care.

What’s the question?

“How much is that?�

There are two things in play in the health care industry that fly in the face of marketplace sense. First is the lack of price transparency. Imagine going to the grocery store and seeing aisles upon aisles of food … without any prices posted.

“How much is that package of chicken breasts?� “That depends. How are you paying for it?�

My guess is that you wouldn’t shop in that market again. Health care is the only consumer-facing industry in the U.S. that doesn’t have price transparency. Worse, if you ask for pricing, you’re often met with blank stares and “I have no idea� as the answer.

Second is how the prices are set. You’ve heard of the medical billing codes – the Holy Codes that state Medicare and health insurance reimbursement payments for everything from lab tests to joint replacement. The price values for each of those billing codes is set by an American Medical Association (AMA) committee called the RUC: the Specialty Society Relative Value Scale Update Committee. This group meets behind closed doors, creates the pricing list for every single medical procedure, and then publishes it. This is not price fixing, since they hand the list to the Centers for Medicare and Medicaid Services (CMS) for publication, the AMA does not publish the list on its own.

Here’s a critical health policy issue: create price transparency. Require providers to know, and share, the cost of the services they provide to the customers they serve: THE PATIENTS. Doing this will accomplish what all the health care blue-ribbon committees and working groups in DC haven’t been able to pull off: downward pressure on health care costs.

Whether you love Obamacare or not, you know that the health care system in the U.S. must change, for the health of our families and communities as well as the financial health of our national economy.

As an example of the results that a health care consumer can get by asking “how much is that?� I offer you a story off the business pages of the Los Angeles Times. One woman discovered that the cash price for the medical procedure she needed was $1,054, but only after her insurer had been billed $6,707, of which her co-pay was $2,336. If she’d asked “how much is that?� she would have saved herself $1,282. That’s a hard lesson, isn’t it?

How broken is the health care payment model in the U.S.? It’s pretty darn broken, as evidenced by that anecdote alone. By asking for pricing information when making health care purchases, we can have a positive impact on our own financial outlook while simultaneously opening up new communication channels with our health care teams. Their work has value. That value, and its pricing, should be transparent to us. We’re paying the bill: through insurance premiums and co-pays, health savings accounts, self-pay for health care, or a combination of all three.

So the next time you’re buying health care services, ask that really important question: “How much is that?� If you don’t get an answer, consider shopping in another health care store.

That will start bending the cost curve!

Disruptive Women in Healthcare

Written by:  Casey Quinlan on October 24, 2012

Casey Quinlan is a digital health activist and author of "Cancer for Christmas: Making the Most of a Daunting Gift". She speaks frequently to both clinician and patient audiences about the power of participatory medicine and data-sharing, and is an advocate for price transparency in healthcare.

This time of year millions of consumers are encouraged to get the flu shot.  According to the CDC (Centers for Disease Control and Prevention), everyone who is at least 6 months of age should get a flu vaccine this season. It’s especially important for some people to get vaccinated.  Those people include the following: people who are at high risk of developing serious complications like pneumonia if they get sick with the flu, people who have medical conditions including asthma, diabetes and chronic lung disease, pregnant woman and people who are 65+.

If you don’t have health insurance, or if your health insurance does not cover the flu shot, it helps to know how to shop around to find the best value.  Many people pay out of pocket for a flu shot and prices for this vaccination can range from $15 to more than $50 if you include the cost of an office visit.

In terms of quality, safety and effectiveness, there is no difference between immunizations at a store clinic or a doctor s office. It’s perfectly safe, says Jim Turner, the executive director for the Department of Student Health at the University of Virginia and a past president of the American College Health Association.  They are buying the same vaccine doctors’ offices buy.  Retailer clinics must also follow state regulations on administering vaccines.L NAME

Even for consumers who get their shots free with insurance coverage, it still pays to shop around for the best flu shot promotions because some of them are far more generous than others. 

Here’s a sampling of flu shot prices and promotions and where consumers can get flu shots.

FastMed Urgent Care -   $15. FastMed has several locations in the Triangle, including Apex, Cary, Raleigh, Chapel Hill, Durham, Holly Springs, Fuquay-Varina and Wake Forest.

Harris Teeter -  $24.95. Through Dec. 31, customers getting flu shots receive coupons for $5 in free groceries. The coupon is good through Jan. 7. And, if you’re a new Harris Teeter pharmacy customer, you’ll receive a $20 grocery credit loaded to your loyalty card.

Kroger -   $25. A recently expired coupon on their website shaved $15 off the price but these digital coupon offers are frequently reissued so it’s well worth checking.

Rite Aid -   $29.99. Customers receive coupon booklets with savings valued at $100 and 25 Wellness+ points that can be applied toward future shopping perks.

Wake County Human Services -   $30. However, the shots are free to many groups of people, including uninsured pregnant women, family members and caregivers of infants under six months of age, students attending any college or university in North Carolina, and children who qualify for the federal government’s Vaccines for Children Program. Weekly clinics are held at the Public Health Center at 10 Sunnybrook Road in Raleigh. Additional clinics are scheduled throughout the county. Go to wakegov.com/humanservices for more information.

CVS -  $31.99. Customers getting flu shots receive 20 percent savings passes valid on regular-price merchandise.

Walgreens  -  $31.99.  Special promotion offered through Oct. 31, customers getting flu shots receive 1,500 Balance Points, which is equal to a $1.50 credit in Walgreens’ new loyalty card program.

Corporations - Corporations often offer their employees flu shots. Business would rather keep employees at work rather than out sick, so offering a flu shot can be a cost saver. Costs range from free to being covered by insurance. Employers often pay an administration fee to have the shots given. Cash payments usually range between $20 and $30.

Doctor's offices - Many often flu shots are given in your local doctor's office. If you have insurance, you will make a co-payment for your appointment. Seasonal flu shots are covered by most insurance policies. If paying cash, a doctor's visit can cost $20 to $200, plus the cost of the shot, which can be $20 to $30.

Retail outlets - Big-box retailers or retail pharmacies also offer flu shots in the early fall. Walmart, Target, Walgreens, Rite Aid Pharmacy and CVS/Pharmacy all offer clinics at certain dates that are subject to change and vary according to location. Check the stores' individual websites for times and locations. Insurance covers the seasonal flu. Cash payments range from $20 to $40.

Senior Facilities - In many communities, local departments of public health offer flu shots to senior citizens. People 65 and older make up 90 percent of deaths from the flu, so health officials often ask seniors to get vaccinated. Medicare Part B covers the cost of a seasonal flu shot for seniors.

Public Facilities - Sometimes flu shots are offered in public locations such as libraries or YMCAs or other public-access facilities in order to reach large segments of the community. These are often sponsored by a local charity or by a public health outlet and usually take cash payments to cover the cost of the shot.

Schools, Colleges and Universities - Colleges and universities often ask students, staff and teachers to get vaccinated. Students in particular often share living spaces and can easily infect one another. Many colleges and universities require students to carry insurance, which will cover the cost of the flu shot.

High prices and limited budgets can keep people from buying the prescription drugs they need. But there are things consumers can do to save money on prescription drugs—and sometimes a lot of money.

Consumer Reports published a Money Saving Guide to help consumers get the best prices on their prescription drugs.  This report includes practical advice and information on:

• How to talk to your doctors and pharmacists about saving money
• How to compare prescription drug prices
• Tips on how to shop around locally
• Advice on how to shop online for prescription drugs
  

Other items of interest on the Consumers Reports website include the Best Buy Drug Report, resource including pharmacy websites, patient assistance programs and state drug discount programs.

More consumers are using the Internet to comparison shop for health care services, according to a new survey.

You shop for purses online, new glasses or sometimes even your groceries. And now, many people are looking for medical services in the same place.

In fact, according to a recent survey by insurance giant UnitedHealthcare, 14 percent of respondents reported using online resources to compare and shop for health care treatments and services.

While that's in contrast to the more than 75 percent who said they use the Internet to shop and compare things like cars and electronics, it does indicate that consumers are moving into Internet health care pricing, UnitedHealthcare found.

In response, UnitedHealthcare is making big improvements to their myHealthcare Cost Estimator, which is an online service that helps consumers find services and compare costs. The new estimator includes mobile versions and the ability to compare quality and cost for more than 574,900 different health care providers and 4,275 hospitals.

But United isn't alone, and many of its competitors are right here in Nashville. MDSave, MedSolutions, Healthcare Blue Book and Change Healthcare, all based in the Nashville area, have services aimed at price transparency.

More Consumers Using the Internet to Comparison Shop for Health Care
By Annie Johnson
Staff Reporter
Nashville Business Journal

Prostate cancer hits one in six American men in their lifetimes, though in most cases it progresses so slowly that it would never cause problems. PSA tests can give an early warning of prostate cancer. But PSA tests also give many false alarms, prompting more than one million unnecessary biopsies every year.

The number of children being treated with prescription medication for attention deficit hyperactivity disorder has soared in recent years. Some doctors, parents and child advocates have become concerned that many children are taking medication unnecessarily. What do you think?

With tens of millions of baby boomers heading into retirement, Medicare’s long-term financial prognosis is grim. One proposed solution is to raise the eligibility age gradually to 67 from 65. What do you think?

People will marry for health insurance, not only in California. But how many will go on national TV?

http://www.cnn.com/video/#/video/bestoftv/2010/02/03/hln.behar.andrew.young.intv.cnn?hpt=T2

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.

Here is an article worth reading about the nature of health care expenses, how we make the decisions about what to spend and how much, and why having your own health insurance policy may mean that you are a better cost risk than someone on a government or employer’s plan:

http://www.cnn.com/2009/POLITICS/06/15/miron.health.costs/index.html

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.

This health insurance question came to me recently and I thought it worth sharing:

We are meeting with our health insurance broker tomorrow to review and select options in providing our employees HMO/PPO health insurance benefits.  We have many options, and many rates in front of us between two insurers.  Would you be able to suggest a few key critical review questions we should be asking our broker both from the perspectives of 1) lowest cost options to the company and 2) acceptable employee options?  We have under 50 employees now, and are going to contribute 50% to the plan for the employees.  None of us are experts in benefits, so we want to be sure we are making the choices in both the best interest of the company and to our employees which range in age from 22 to 75, half of which are over 50. 

From a benefits perspective, you certainly know more about what it takes to attract and retain employees in your industry. My recommendation is to make sure you get all the numbers to make your health insurance spreadsheet for comparison and know how high a health insurance deductible your group will be able to tolerate (the higher the health insurance deductible, the lower the monthly health insurance rate). Depending on the group of employees and creative strategies allowed in your state, some companies are able to create reimbursement packages for employees such that they buy their own health insurance and/or receive HSA contributions from the employer.

Buying health insurance will be an annual exercise for your company, and of course there are other options such as employee leasing companies that can handle all of these details for you. Be sure to check out news stories (such as those from the LA Times and the Wall Street Journal) on these health insurers as well as to check them out via the free online databases in the health insurance resources center. You may also wish to make sure you are considering all of your options by looking at the insurers rated best at in the health insurance resource center and ensuring that you have health insurance quotes from them.

Best wishes on your search.

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.

I know it sounds crazy, but did you know that if you move to another state you may easily get health insurance, no questions asked? The reason is because some states do not allow medical underwriting when applying for health insurance, whereas the bulk of them do. So those states that don’t allow medical underwriting are much easier to get health insurance regardless of medical status – the application forms don’t involve disclosing your detailed medical history.

Sure there’s a waiting period for pre-existing conditions (perhaps six months), but then you’ll have your health insurance – and having health insurance is an essential component of many people’s financial picture. For whatever reason you no longer have health insurance, whether it due to an illness, a family situation, a layoff, or one of the many other reasons, getting it back can be essential. Relocating to a friendlier state may be your solution, along with considering the other options available without moving, including obtaining employment that offers health insurance or buying your own (and making sure that you know all of your options – that’s why I wrote a book on health insurance!)

Moving is not to be taken lightly – there are many consequences and expenses involved with moving. However, you can move to your new state in a very lightweight way, simply by establishing a residence consisting of no more than a studio apartment or a bedroom in a shared house. As you further transition to your new state, you may begin moving more items to the new state, and continue to make your transition. Some people never move everything they own to a new state, but have a second residence elsewhere (such as the scenario that many retirees desire – with a residence in Florida and a second home elsewhere). So long as you meet the defined requirements of residency in your new location, you’ll still continue to be able to travel and visit anywhere that you wish.

So which are the states that offer guaranteed issue health insurance without medical underwriting? Presently the short list of states includes:

• Maine Health Insurance
• Massachusetts Health Insurance
• New York Health Insurance
• New Jersey Health Insurance
• Vermont Health Insurance

A few more states that I’ve found have special programs that really help people in need of guaranteed issue health insurance (check with your state department of insurance as well as others before you make a move):

• Oregon Health Insurance
• Washington Health Insurance
• Michigan Health Insurance
• Rhode Island Health Insurance

If you don’t wish to move, then you may find that your state offers guaranteed issue health insurance, subsidized rates for certain income levels, and special programs and special times of year when health insurance is not medically underwritten. There may also be specific special programs for those that have lost employment due to jobs moving overseas, or certain other industry and natural events. The best place to start finding out about these programs is with your state department of insurance. You can find contact information for your state department of insurance at State Health Insurance Resources at http://www.besthealthinsurancebook.com/state-health-insurance-resources/

As always, consult your team of financial and medical professionals before making a move. With these ideas and their advice, you may be better off.

This post originally appeared at HealthCentral.com at http://www.healthcentral.com/caregiver/c/76590/31355/insurance-move

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.

Cato Institute’s Michael Cannon hosts this compendium of insurance/risk related posts

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website www.BestHealthInsuranceBook.com. Copyright 2007-2008 Aji Publishing.