Health Insurance News and Blog Feeds

A group proposes some standards for privacy and security for downloading personal medical info.

We assumed medical societies and associations in all 50 states would sign on to the letter, but groups in Alabama, North Dakota and Kansas did not.

[Welcome Reason readers!]

Then why are there so many health insurance companies retreating from the market, leaving consumers with fewer choices and higher premiums? Since March when Obamacrap was signed in to law we have seen the following changes in the Georgia health insurance market. (Other states have had similar issues, but I am only familiar with Georgia health insurance plans).

All but two health insurance companies have withdrawn from offering maternity benefits.

Only a handful of companies will still write "child only" health insurance plans.

As of this date, it is almost impossible to find a rate for children's health insurance if they are under age 19 and you are looking for coverage to be effective on 9/23/10 or later.

Some companies have either withdrawn from offering major medical business or are dropping hints they will be out of that market in 18 months or less.

Many have already indicated higher premiums for the 4th quarter of 2010 and later, especially on children under age 19.

Companies are starting to push limited benefit plans as "more affordable" alternatives to true major medical insurance.

Several companies have introduced new plans with stripped down benefits in an attempt to make their product look more appealing.

Drug formulary's are changing, so the drug that is covered under your plan now may not be covered in the future.

Doctor and hospital networks are shrinking in an effort to further control costs but also has the effect of limiting access to a wide range of medical providers.

Given all this, why is Obamacare so great for the consumer?

What happened to , "If you like the plan you have now you can keep it"?

What does the Capitol Visitors Center and Obamacare have in common?

The CVC was supposed to make it easier for visitors to access Washington landmarks and make their visit more pleasant.

The CVC originally was supposed to take 4 years to build at a budget of $71 million. When completed it took 8 years and cost $621 million.

Obamacrap is supposed to make health insurance more affordable and accessible to everyone, regardless of their age, gender or existing medical conditions.

The initial estimate is the cost of Obamacrap will be less than $1 trillion over 10 years but those figures are already fading in the light of day as the Congressional Budget Office and others are wading through the bill . . . after the fact of course. The final cost will not be known for years.

This makes one wonder, if Washington can't even get a construction project to come in on time and within budget, how can we expect them to do any better with health care?

Just 5% of small firms reported reviewing performance indicators of health plans' clinical and service quality.

Also: Stem cell legislation in the House; Abbott ends an auction; NYC public hospitals prepare for some changes.

The Health Business Blog is on summer vacation until Labor Day, and has been re-running some classic posts for the past two weeks. This is the last one.

This item originally ran on April 24, 2008. It’s one of a number of posts I’ve run encouraging the medical profession to take more care to limit radiation doses from imaging. If you’d like to comment, please do so on the original post.

American Imaging Management (AIM), a radiology cost containment company owned by health insurer WellPoint, has a web-based patient exposure tool called Aimee that provides information for doctors and patients about the amount of radiation associated with various scans.

The site is well-designed and easy to use. Simply click on the relevant scan and portion of the anatomy and the site provides a summary of the purpose of the exam and suggests safer alternatives when appropriate. At the bottom of the page is a display that expresses the radiation exposure in millisieverts (mSv) and as its equivalent in chest x-rays and background exposure. I like the site because it raises awareness about radiation exposure and provides alternative recommendations patients could discuss with their physicians.
According to AuntMinnie, a radiology news and information site, some physicians are less sanguine. See Criticism aimed at radiation-estimate Web site. Among the complaints:

1. Ownership of the site by a party that has a stake in reducing imaging costs
2. The site’s oversimplification, e.g., not specifying that radiation exposure depends on equipment and protocol, not just the type of scan category
3. The inappropriateness of making comparisons with chest x-rays (e.g., for scans that target other parts of the body) and background exposure (because the exposure comes over time rather than all at once)
4. Lack of relevance for pediatric patients, who will get lower exposures
5. Lack of discussion of the benefits of imaging

Some of these criticisms are reasonable and I hope AIM takes them into account as it updates Aimee. Still, I don’t think they’re completely fair:

1. Ownership: As long as AIM’s information is objective, I don’t think it matters who owns the site.
2. Oversimplification: I’m sure there are improvements that can be made, but I don’t know if that would really make the information more useful. Perhaps just indicating that there is a range would be enough. This criticism sounded more like an objection to having the information posted at all.
3. Appropriateness of comparisons: Since most people don’t understand mSv, the other comparisons are at least somewhat helpful. And it’s not as dramatic as comparing the exposure to the level of radiation received by atomic bomb survivors, which I’ve also seen!
4. Pediatric: This is an important consideration. On the other hand, as the Image Gently folks have described, pediatricians and radiologists have plenty of room for improvement on radiation exposure practices. Casting stones at Aimee won’t really help.
5. Lack of discussion of benefits: Imaging is a large, rapidly growing contributor to medical spending. There’s no particular need for Aimee to talk about imaging’s benefits.

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A recent article by Joe Paduda about the impact of the recession on health care explains what most of us have probably already suspected: Americans have cut back on their use of routine medical care.  I’d say that it’s also highly likely that the increasing number of uninsured people over the last couple years is contributing to the problem.  Employers have been less likely to offer group health insurance because of the recession, and there are a lot more unemployed people than there were a few years ago.   In addition, individuals who purchase their own health insurance – especially those who are currently healthy – have been more likely to drop their coverage in order to fulfill other financial obligations.  Not only does that leave them completely vulnerable if they do become sick or injured, but it also drives up health insurance premiums for the people who remain on the policy, which in turn leads to more people dropping their coverage because they can’t afford the premiums.

I haven’t seen any new data released recently comparing the population with health insurance in 2007 versus 2009, but my guess is that there are a lot more uninsured Americans now than there were a few years ago.

As Joe pointed out, higher deductibles and copays also play a role.  Two years ago, before the recession had really taken hold, researchers had already found out that people with high deductible health insurance policies were two to three times more likely (compared with people covered by traditional health insurance plans) to stop taking medications to control chronic conditions.  For people who opt for a HDHP but then don’t set up and fund an HSA, paying for health care can indeed be a major hurdle.  And if people with high deductible health plans were skipping their meds back in 2008, it makes sense that after two years of a recession, health care costs have taken even more of a backseat for families struggling to make ends meet.

Copays and deductibles have risen for most families over the last few years, even those who don’t have policies that qualify as high deductible.  And at the same time, economic stability has decreased for most families.  This isn’t a good combination, and Joe’s right about the fact that when people skip necessary routine medical care, it will likely lead to increased medical costs (and declining health) in the future.

Joe’s article was included in the Health Wonk Review this week, hosted by InsureBlog.

One of every five kids and 9 of 10 older Americans took at least one prescription drug in the previous month, says a survey taken in 2008.

In an effort to standardize the provision of medication therapy management (MTM) within Medicare Part D, CMS has outlined specific requirements for Part D Plan MTM programs in 2010.  The APhA’s Medication Therapy Management Digest (March 2010) reviews these requirements.

MTM programs must:

• Enroll targeted beneficiaries using an opt-out method only (i.e., beneficiaries are automatically enrolled unless they choose not to be)
• Target beneficiaries for enrollment at least quarterly.
• Include the following enrollment criteria for targeted beneficiaries:
  • Does not require more than three chronic disease states.
  • Does not require more than eight medications.
  • In defining multiple chronic diseases, sponsors must target at least four of seven core chronic disease states.
  • Likely to incur annual costs of $3,000 for covered Part D drugs (a reduction from the previous requirement of $4,000).

Part D plans’ MTM programs must include, at a minimum:

• An annual comprehensive medication review, including a review of medication use, interactive person-to-person consultation (face-to-face or by phone), and a written summary.
• Quarterly targeted medication reviews.
• Active interventions (i.e., not limiting interventions to mailings and refill reminders).

Plans must measure and report the number of:

• Comprehensive MTM visits.
• Targeted MTM visits.
• Provider interventions.
• Changes in therapy as a result of interventions.

The latest edition of the Health Wonk Review is up at Hank Stern’s always interesting InsureBlog.

The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on April 6, 2009. It’s one of a number of posts I’ve run in favor of a liberal immigration policy. If you’d like to comment, please do so on the original post.

Immigration of skilled workers has been a key driver of economic growth and innovation in the US in health care and throughout the economy. However, we are in real danger of losing that edge. The US has made immigration more difficult by restricting visa availability; there has been a fair amount of immigrant bashing as well. See (Biting the hand that feeds you, sutures you, fills your prescription…) Meanwhile, economic conditions in places like India are improving significantly, so there’s less of a willingness to jump through hurdles and then be met with less than full acceptance.

The problem is only getting worse with the current depression. Economic opportunities are declining in the US overall and politicians are using the bailout funds and stimulus program as a chance to try to channel funding away from foreign workers.
An article in today’s Wall Street Journal (Ineligible Bachelors: Indian Men Living in US Strike Out) put the issue in personal terms:

Indian parents used to think it a plus to marry off their daughters to Indian men living in wealthier countries, including the U.S. and Britain. But as India has grown more affluent in recent years, the demand for overseas Indian grooms has been fading. While India’s economy is also slowing down, it is still growing, and layoffs aren’t as widespread as in the West…

Career-oriented Indian women, meanwhile, have grown concerned about their job prospects in the U.S. Sandeep Gohad, a Manchester, Conn., software consultant who’s between jobs, got such questions during a two-month-long visit to his hometown of Pune, near Mumbai. He told bride candidates they would have a hard time getting a work visa in the U.S. And even if they did, finding jobs would be tough. He, too, came home single. An engineer or doctor “has absolutely no reason to go to the U.S.A. and work as a housewife,� he says.

If skilled professionals can’t get visas they won’t come to the US, and if they can’t get married they won’t stay. It’s a problem for many industries. In health care, for example, it means the shortage of primary care physicians in small towns and rural areas will get worse.

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Back in March, the Colorado Division of Insurance launched a review of the rate increase they had previously approved for Anthem Blue Cross Blue Shield individual policies.  It was a process that was supposed to be finished in just a couple months, but might end up taking the rest of the year as analysts consider all of the data involved in determining what rates were appropriate for 2010.  Anthem is so far the only Colorado carrier that has been subjected to such protracted scrutiny by the Division of Insurance, but as we noted when the issue first came up, Anthem’s 2010 rates were very much in line with what other individual carriers were charging this year.  It remains to be seen whether other carriers’ rate increases will be reviewed this thoroughly in future years, but one of the provisions on the PPACA is to provide money to the states specifically for the purpose of reviewing proposed rate increases.

Colorado will get $1 million to use for more extensive review of future rate increases, and the Division of Insurance has proposed hiring more analysts and actuaries to examine the data that is filed each year by the insurance carriers.  The rate proposals will get more scrutiny, which is a good protective measure for consumers.  But insureds could still see hefty rate increases thanks to the ever-increasing cost of health care.  In CA, after months of review, regulators still approved a double digit rate increase for Wellpoint policies (14% average, with individual increases as high as 20%).  If the cost of health care continues to increase at its current pace, health insurance premiums will also continue to climb.  A more thorough review of the extensive data involved in determining health insurance premiums makes sense, but without significant measures to cut the cost of health care, those reviews may find that there is no way around raising premiums year after year, often by noteworthy amounts.

Currently, Medicare and private insurers are attempting to put in place incentives to reduce the number of readmissions. Visits to the hospital are costly and reducing the frequency of hospital visits is the best means to reduce medical costs. In particular, if readmissions are the fault of the care the patients receive during the initial admissions, hospitals should be liable for subsequent care.

On the other hand, a recent letter to the New England Journal of Medicine, argues that high readmission rates may in fact indicate high quality care.

“A higher occurrence of readmissions after index admissions for heart failure was associated with lower risk-adjusted 30-day mortality. Our findings suggest that readmissions could be ‘adversely’ affected by a competing risk of death — a patient who dies during the index episode of care can never be readmitted. Hence, if a hospital has a lower mortality rate, then a greater proportion of its discharged patients are eligible for readmission. As such, to some extent, a higher readmission rate may be a consequence of successful care.”

The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on August 27, 2008.  If you’d like to comment, please do so on the original post.

The distribution of prescription pharmaceuticals is beginning to take on some of the characteristics of online videos and music. Traditionally, access to prescriptions works as follows:

1. Patient has a problem
2. Patients sees his/her physician
3. Physician diagnoses problem and writes prescription
4. Patient takes prescription to traditional pharmacy or PBM-owned mail order company
5. Pharmacy fills prescription with a drug manufactured by an FDA-regulated brand name or generic pharmaceutical company
6. Patient takes medication
7. If patient needs more medication after initial prescription and refills are exhausted, patient requests renewal from physician and repeats steps 4 to 7

But steps 2 through 7 are breaking down. Instead of seeing their physicians, increasing numbers of patients are either going directly online to order from pharmacies or are borrowing pills from friends and family who’ve received prescriptions. According to MedPage Today (Adults Commonly Share Prescription Drugs with Friends and Family) almost 30 percent of adults reported sharing prescription medications with others. Younger people are the most likely to share.

Meanwhile, shady web-based pharmacies that don’t require prescriptions and often sell counterfeit drugs are becoming increasingly sophisticated and impressive. MarketMonitor estimates that about 1000 shady pharmacy sites generate an average of 100,000 hits per day each and that such pharmacies spend about $25 million per year on search advertising. An acquaintance who works in the pharmaceutical security business told me that these pharmacies aren’t what they used to be. In fact they are adopting marketing and customer service best practices that are used by legitimate vendors. Rather than going for a quick score, the web-based companies are looking for repeat business and word-of-mouth referrals by providing products that work, offering easy-to-navigate websites and low prices.

This isn’t quite the same as what’s happened in the field of digital music and video, but there are similarities:

• The intellectual property violators (e.g., Napster, YouTube, shady pharmacies) have made it easier and more convenient for consumers to get what they want –either for free or cheaply
• Traditional players have had a hard time reacting (e.g., the big music companies, the big pharma companies). In music this has led to a major loss in sales and it’s also meant that the record labels have been willing to sell online. The emergence of DRM-free music downloads is due to the existence of free –though illegitimate– alternatives. It’s also allowed iTunes to gain leverage over the record companies

There are some important differences, though:

• Unlike digitial music files, counterfeit pharmaceuticals aren’t exact copies of the originals –and it’s much harder to tell the difference
• The existence of insurance and general acceptance of the doctor’s role in prescribing means there’s less demand for free, presciptionless drugs
• Pharmaceuticals are physical products, so it is possible to secure the supply chain

Still I wonder whether some of the shady websites will end up going legit (like Napster) and whether pharma companies will be forced to react (e.g., by pushing for OTC clearance of lifestyle drugs that are still on-patent or by bundling services in with their products).

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Earlier this summer, HHS announced that businesses could begin submitting applications to the newly-created Early Retiree Reinsurance Program in order to receive federal funding to help pay for retirees’ health insurance until they become eligible for Medicare.  To date, 2000 businesses have been approved for the program, and HHS Secretary Kathleen Sebelius says that this is just the beginning.  Businesses have shown great interest in the reinsurance program, and Sebelius notes that they have received applications from “… more than 50 percent of Fortune 500 companies, all major unions, and government entities in all 50 States…”

Applying to the program is an obvious step for a business that would like to continue to provide health insurance for early retirees.  But the question remains as to whether the $5 billion designated for the ERRP will hold out until 2014 when all of the provisions of the PPACA become effective.  But between now and then, having the option to remain on a previous employer’s group health insurance plan does take a lot of pressure off of early retirees, especially those with health problems who may have difficulty securing individual coverage.

Whether the money will last or not remains to be seen.  But for now it looks like a good option for employers who are looking for a helping hand in providing health insurance for their early retirees.  For people in Colorado who retire before age 65 and don’t have employer-provided early retiree health insurance benefits, there are lots of options available in the individual market, although those do require that the applicant be reasonably healthy in order to qualify.  For those who don’t qualify medically, there are two guaranteed issue programs available in Colorado now:  Cover Colorado and GettingUsCovered.  They aren’t cheap, but they are guaranteed issue for people with medical conditions that preclude medically underwritten individual policies.

• California Workers Comp: Parts I and II.
• Decriminalizing drugs in the Czech Republic.
• Bad news for Alzheimer’s Treatment
• The solution to obesity: school playgrounds?
• An interview with a nurse practitioner.
• Homo economicus in Paris.

Oftentimes, people use the following rule of thumb: if the dependent variable is continuous, use OLS; if binary use a logit or probit.  But what should you do if your dependent variable is fraction between 0 and 1.  To use a logit or probit one would have to unnecessarily transform the dependent variable into binary form.  If one would use OLS, the estimation of the coefficients would likely be incorrect.  Because the dependent variable is bounded between 0 and 1, the effenct of any explanatory variably x_j cannot be constant through its entire range. Additionally, the predicted values from an OLS regression often produce figures outside the range of 0 to 1.

A paper by Papke and Wooldridge (1996) examines potential econometric alternatives when your dependent variable is fractional.

LOG-ODDS RATIO

One option to estimate a fractional response variable is to transform the dependent variable into a a log-odds ratio.  For instance:

• E(log[y/(1-y)]|x) = xβ

This model is simple and can be estimated with OLS techniques onces the depenent variable is transformed.  It only works, however, when the dependent variable is strictly between 0 and 1. [If y=0 the you have the log(0) and if y=1 then you get the log(1/0) which is ∞].   Additionally, using this framework, it is difficult to recover E(y|x).  Under the model specified above:

• E(y|x)=∫ {exp(xβ+ν)/[1+exp(xβ+ν)]} * f(ν|x)dν

If the residuals are independent of the explanatory variables (i.e., ν⊥x), one can use Duan’s (1983) smearing technique to estimate f(•).   If not, one must make functional form assumptions regarding the distribution of the error terms.

QUASI-LIKELIHOOD METHODS

Papke and Wooldridge support using quasi-likelihood methods. Assume the following relationship:

• E(y|x) = G(xβ)

where 0<1 for all z∈ℜ. The most popular choice for G(z) is the logistic function where G(z)=exp(z)/[1+exp(z)]. In this model, one can estimate the parameters β using the following Brenoulli log-likelihood function:

• l_i(β) ≡ y_ilog[G(x_iβ)] + (1-y_i)log[1-G(x_iβ)]

This method has several advantages.  First, it is fairly easy to estimate.  Secondly, the equation above is a member of the linear exponential family thus the quasi MLE method will produce a consistent estimator of β where β is normally distributed.  Assuming a logit function for G(z) produces the following variance:

• Var(y_i|x_i) = σ² * G(x_iβ)[1-G(x_iβ)]

The Papke and Wooldridge (1996) also describe how to compute the asymptotic variance of the estimator β.

• Papke LE and Wooldridge JM (1996) “Econometric methods for fractional response variables with an application to 401(k) plan participation rates“, Journal of Applied Econometrics, v11:619-632.

The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on April 18, 2007.  Mini-meds look dead due to health reform, but depending on how things goe they may come back. If you’d like to comment, please do so on the original post.

I’m not enthusiastic about Mini-Med plans –the policies that offer limited coverage, often capped at $25,000 to $50,000 per year. In some ways they are the opposite of insurance because they pay for routine expenses but don’t cover catastrophic ones. In fact, I’ve come out repeatedly in favor of scrapping insurance for routine costs, like prescriptions.

I have to admit there’s another side to the story, and admit that my personal perspective on this has been colored by the fact that I can afford traditional coverage.
The Wall Street Journal ran a very informative piece on page 1, today (Covering the Uninsured, But Only up to $25,000). It focuses on Tennessee’s state-sanctioned mini-med coverage, CoverTN, and repeats some of the common criticisms:

Alan Sager, a professor of health policy at Boston University, calls the Tennessee plan “flimsy insurance� that will merely “provide cover for employers to save money.� Adds University of Tennessee medical-school professor David Mirvis, “It may be better than nothing, but it’s not real insurance.�

These experts are right.

On the other hand:

…Gov. Bredesen says he listened to focus groups and queried blue-collar folks, such as a waitress at a waffle restaurant, to devise his plan. “They weren’t interested in buying insurance for catastrophic events. They wanted access to the emergency room next month, access to the pharmacy next month,� he says. “Let’s give people what they want instead of what some advocate says they want.�

What Bredesen understands, but Sager and Mirvis downplay, is that a $10,000 or $25,000 or $50,000 debt falls into the “catastrophic� category for a lot of people. It can mean filing for bankruptcy or taking many years to dig out of debt. There’s not such a big difference between owing $50,000 and owing $1 million. Both amounts are in the category of not being repayable. Many people who run up debts of either amount are going to be eligible for Medicaid in any case.
On the other hand, if a person of modest means buys a comprehensive policy, it’s likely to be expensive and have high deductibles and co-pays. In addition to having to scrape together the money to pay the premium every month, a moderately expensive episode of care could still end up causing financial hardship or ruin.

For example:

Sherry Slatton, 46, a nine-year veteran in the Pepper Patch kitchen, dropped her comprehensive health insurance through her husband’s employer. The couple enrolled in the CoverTN plan, and their monthly cost will drop to about $175 from $350. Ms. Slatton wasn’t happy with the old coverage, which she says stuck her with $4,000 in charges when she underwent surgery to remove a benign cyst.

There’s also a stigma associated with being uninsured, and Mini-Meds address that, at least to some degree:

Ms. Robinson, the 23-year-old kitchen worker, figures it can’t get any worse than being uninsured. A nonprofit clinic recently told her she couldn’t get an appointment for a sinus problem for three weeks. Last summer, she went to a hospital emergency room for an infection. She says she was treated rudely, never saw a doctor and couldn’t get a prescription for an antibiotic from a nurse. Now, she’s paying $47 a month to the hospital to pay off her $3,000 debt. Her CoverTN premium is $41 a month.

“You walk in the hospital without insurance, it’s like you don’t even matter,� says Ms. Robinson.

I still dislike Mini-Meds –especially those sold by companies that engage in deceptive marketing practices– but we should acknowledge that not everyone who buys them is irrational or uninformed.

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on December 23, 2009. I took a lot of undeserved flak for this one. Maybe people thought I was being disrespectful toward nurses. If you’d like to comment, please do so on the original post.

In Nursing crisis looms as baby boomers age, CNN Money repeats a well-known story: there are unlikely to be enough nurses to take care of people as they age. Nursing schools can’t keep up with the demand and trouble awaits. We’ll face a shortage of 260,000 RNs by 2025, we’re told.

I don’t really believe it’s such a big deal.

There are two good solutions to the problem, and they aren’t mutually exclusive:

1. Increase the recruitment of nurses from abroad
2. Substitute technology for labor

The first option is already in effect to some extent. But anti-immigrant attitudes and rules limit the number of non-US nurses here. There are also an ethical considerations; when nurses from middle income countries like South Africa and Thailand come to the US, it creates a shortage of nurses in those countries. Some of those shortages are filled by bringing nurses from poor countries to middle income countries. That leaves the poor countries bereft at a time of tough challenges such as HIV and TB.

The second solution essentially means replacing at least some nurses (or some of their functions) with technology, including robots. A lot of things nurses do will be doable by machine, if not this year then certainly by 2025. These robots will take many forms, but one could certainly be as a “personal medical assistant� that handles most mundane functions. It could check vitals, provide encouragement, remind patients to take their medications, and go beyond those tasks to other areas, such as playing games, cleaning the house, making food, and even engaging in pleasant conversation.

This technology trend shouldn’t encounter too much resistance from nurses, who after all should still have plenty of opportunities for employment.

The nursing workforce issues are real, but they provide opportunities for innovation, not cause for panic.

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Throughout this year, the Independence Institute has been working to get a measure on the ballot in Colorado to block the health care reform legislation that would require everyone to have health insurance starting in 2014.  Yesterday, the Colorado Secretary of State confirmed that the amendment supporters have gathered enough signatures to get the measure on the ballot, so it will be up for a vote in November.

Interestingly, the amendment wording does not make any attempt to reverse the provisions in the PPACA that require health insurance carriers to accept all applicants as of 2014.

If I understand it correctly, the backers of the Right to Health Care Choice Initiative want a health insurance system that would require health insurance carriers to accept everyone who applies (since they seem to have no problem with that part of the PPACA), but with no requirement that people purchase health insurance.  While I can understand the desire to be free from government regulations that direct how we conduct our lives, this particular freedom only works if the health insurance carriers can be free to determine which applicants they will accept and which they won’t (the way our system currently operates).

Most people I’ve talked to can see the problem we would have if we were to remove the guaranteed issue aspect of health care reform but keep the mandate portion (ie, require everyone to purchase health insurance but still allow health insurance carriers to underwrite based on medical history).  For some reason, the opposite scenario doesn’t seem as far-fetched to a lot of people.  But in reality, it just wouldn’t work.  I cannot see any conceivable way that health insurance premiums wouldn’t dramatically increase if all individual policies had to be guaranteed issue but people could come and go as they pleased from the health insurance system.

Regardless of whether amendment 63 passes or not this fall, federal law still overrules state law and Colorado will have to go along with the provisions of the PPACA unless there are changes to the law on a federal level.  But it will be interesting to see what the people of Colorado think about this issue.

Jaan Sidorov of the Disease Management Care Blog has started deciphering the specifics of the Medical Loss Ratio requirements, and it looks like the National Association of Insurance Commissioners (NAIC) is taking a rather inclusive view of medicine in their interpretation of the law.  Ever since the MLR minimums were laid out in the PPACA, there has been much debate over what would be considered administrative costs.  It’s heartening to see the NAIC giving so much leeway in terms of what will be considered medical expenses.

On page 8 of the proposal, it’s noted that community benefit program expenses “for activities or programs that seek to achieve the objectives of improving access to health services, enhancing public health and relief of government burden” can be included in medical expenses.  So can expenses related to avoiding repeat hospitalizations (including post-discharge counseling) and expenses for programs that improve patient safety and reduce medical errors (page 17).  In addition, wellness program (ie, programs designed to help people combat obesity or tobacco use, public health education, ect.) expenses can be counted as medical expenses.

Some aspects of a medical loss ratio are pretty clear: health insurance employee and broker salaries, for example, are obviously not medical expenses and can pretty easily be noted in the administrative expense column (15% – 20% of premium dollars will still be allocated to administrative costs – those expenses are real and necessary).  On the other hand, payments to hospitals and doctors for acute care are obviously medical expenses and should count as such.  But there are a lot of grey areas in between, and the proposal released by the NAIC looks like it takes a very broad view of what comprises medical expenses.  This should please a lot of people who may have been worried that the MLR requirements were going to signal the end of things like insurer-funded wellness programs and disease management.

Jaan’s article was included in the Cavalcade of Risk this week.

My family has a high deductible health plan with a $5,200 annual deductible and a Health Savings Account (HSA).  I really like our health plan because it provides my family with great coverage in case of any major medical events, and our monthly premiums are considerably lower.   In a typical year, we never meet this deductible.   

This calendar year my family has accumulated some medical expenses and it looks like we might be meeting our deductible by the end of the year.   I have a number of prescriptions filled at our local Walgreens Pharmacy so I joined the Walgreens prescription savings club to save 25% on all my prescriptions.   This is a huge savings for my family.  Almost a month ago I realized my prescription out-of-pocket spending was not being applied towards my annual deductible and since this was almost $2000 in Rx expenses – I was concerned. 

It turns out that if you join the Walgreens savings club and use your savings club discount when you pay for prescriptions, Walgreens does not submit these drug claims to your health insurance plan.   In order for these expenses to be applied to my deductible, I am required to submit these receipts myself.  Why Walgreens cannot forward these claims is a mystery.  But now that I know, I will make sure these drug expenses get applied to my deductible.

This article by Jillian Berman, was published in the July 30, 2010 issue of USA TODAY.

As Alan Grunberg neared 50, he knew he was going to need a colonoscopy, so the Chicago-based Realtor began shopping around to try and find the best place to get the procedure done.

"I couldn't get anybody to give me information on how much it was going to cost," he says, adding that his insurance wouldn't cover the procedure.

Grunberg eventually found PriceDoc.com and received multiple quotes. "The price was outstanding," he says. "I jumped on it."

PriceDoc is one of several sites that give consumers the ability to shop for procedures ranging from a colonoscopy to teeth whitening. In some cases, the sites allow consumers to negotiate with providers.

Steven Findlay, health analyst for Consumers Union, says sites listing prices for procedures can be helpful, but consumers shouldn't settle for the first price offered. Unlike traditional retailers, health providers don't usually advertise sales, he says.

Patrick Bradley, PriceDoc's co-founder, says his goal is to help consumers find a low price for services their insurers won't cover. Patients search by ZIP code for a list of doctors and their prices.

Some of the doctors listed on the site prefer to negotiate and include the "make me an offer" button on their profile, while others just list their lowest price, Bradley says.

"We've created a free, market-based competitive field if you're paying with cash," he says.

One drawback is that for some locations and procedures, the choices are limited. When Grunberg tried to use PriceDoc again to search for a dermatologist, he couldn't find any providers in his area. "I'm not going to travel 500 miles to have something done unless I need to do it," he says.

Bradley says most of the consumers using his site are looking for dental, vision, cosmetic and dermatology procedures. Many have individual insurance policies, which typically have high deductibles, or are paying for care out of a health savings account.

Mona Lori, founder of OutOfPocket.com, says her customers are primarily interested in prices for dental and vision procedures. Lori created the site, which offers a price-based directory of health care services, in 2007 after unsuccessfully trying to get providers to give her prices for various procedures.

Findlay says providers are gradually becoming more transparent with prices.

Brian Douglas, co-founder of New Choice Health, says that should be the goal. Douglas says he started NewChoiceHealth.com, which lists price ranges for procedures at various facilities, to "help educate the consumer that health care is retail.

Deaconess Hospital Medical Imaging, located in Cincinnati, Ohio, is focused on providing patients with the same superior, high quality imaging services -- but at a lower cost.  Deaconess has recently announced new, flat pricing for MRI, CT Scans and Diagnostic Ultrasounds, whether you are a self-pay or have private insurance.   Here are some of the details on their new pricing.

• Deaconess offer a low, flat-rate price for three different medical imaging scans, so that consumers and their doctors know in advance the cost of certain tests, including CT Scans, MRI Scans and Diagnostic Ultrasound procedures.

• Deaconess works with the Radiologists, so the price includes both the Hospital and Radiologist fee.  

• One price for each of the three types of scans (regardless of body part), so that our pricing would be both simple and transparent.

• Consumers with high deductible health insurance plans with health savings accounts, consumers who have private health insurance plans with allowable fees above our new prices, as well as consumers who pay directly for their health care, can all save money.

• The new flat prices have reduced the costs for several insurance plans by reducing the mutually agreed upon contractual price.

• Deaconess recognizes that consumers make decisions based on the lowest cost and the highest quality.  Deaconess offers other features and services including the convenience of same day scheduling and a very quick turnaround of results.

• These prices do not apply to consumers with Medicare or Medicaid coverage.  The new prices set by Deaconess are above what the government pays the hospital and the hospital is not allowed to offer price discounts to either of these government plans.

The Surgery Center of Oklahoma is a 32,535 square foot, state-of-the-art multispecialty facility in Oklahoma City, owned and operated by approximately 40 of the top surgeons and anesthesiologists in central Oklahoma. The facility has been accredited by the AAAHC since 1998 without interruption and has annually provided care to thousands of patients.

If you have a high deductible or are part of a self-insured plan at a large company, you owe it to yourself or your business to take a look at our facility and pricing which is listed on our website. If you are considering a trip to a foreign country to have your surgery, you should look here first. Finally, if you have no insurance at all, this facility will provide quality and pricing that we believe are unmatched.

It is no secret to anyone that the pricing of surgical services is at the top of the list of problems in our dysfunctional healthcare system. Bureaucracy at the insurance and hospital levels, cost shifting and the absence of free market principles are among the culprits for what has caused surgical care in the United States to be cost prohibitive. As more and more patients find themselves paying more and more out of pocket, it is clear that something must change. We believe that a very different approach is necessary, one involving transparent and direct pricing.

Transparent, direct, package pricing means the patient knows exactly what the cost of the service will be upfront. Fees for the surgeon, anesthesiologist and facility are all included in one low price. There are no hidden costs, charges or costs.

The pricing outlined on our website is not a teaser, nor is it a bait-and-switch ploy. It is the actual price you will pay. We can offer these prices because we are completely physician-owned and managed. We control every aspect of the facility from real estate costs, to the most efficient use of staff, to the elimination of wasteful operating room practices that non-profit hospitals have no incentive to curb. We are truly committed to providing the best quality care at the lowest possible price.

G. Keith Smith, M.D.
ksmith@surgerycenterok.com
The Surgery Center of Oklahoma

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A new research paper from The Healthcare Blue Book entitled Surgery Pricing Secrets: The Challenges Patients Face, shows that it is almost impossible to get prices ahead of time if a patient plans to have surgery in a hospital.

Healthcare Blue Book researchers found that:

§ It took three times as many phone calls and four times as long to get pricing information from a hospital.

§ Hospitals would not provide guaranteed prices and price ranges often varied by more than 100%.

§ ASCs were more likely to discount prices for cash customers; regardless of the patient’s financial status.

§ Facility fees are 3-4 times higher in a hospital than in an ASC.

> Healthcare Blue Book researchers contacted hospitals and ambulatory care centers (ASCs) in three markets: Raleigh-Durham , NC ; Denver , CO ; and Portland , OR . Hospitals and ASCs were asked to provide the costs of an anterior cruciate ligament surgery of the knee for a patient without health insurance.

Queries were primarily about facility fees, but researchers also asked respondents about other fees associated with the surgery.

It’s almost certain health care expenditures, which totaled about $2.5 trillion in 2009, will continue to climb by at least 6% a year. Hospital costs are 31% of the total according to the Centers for Medicare and Medicaid Services. So what are health care consumers going to do?

The Healthcare Blue Book, an Internet content provider, offers a free consumer guide to fair pricing for healthcare treatments and services for local markets.

“One of the main tenets of successful healthcare reform will be patients taking more responsibility for finding out what their care costs as they make treatment decisions,� said Dr. Jeffrey Rice, Healthcare Blue Book CEO, and white paper author. “But until hospitals are able to provide exact pricing, managing out of pocket costs for both insured and self-pay patients is almost impossible.�

Click here or a free copy Surgery Pricing Secrets: The Challenges Patients Face.

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.