The folks at Investors Business Daily wondered how Medicare would change if Obamacare becomes law. They interviewed Susan Berson of the Mintz Levin law firm in Washington, DC. She missed the first question, but managed to save most of the interview with later responses.

IBD: Let's start with the drug benefit known as Medicare Part D and the coverage void called the doughnut hole, where retirees pay full price for drugs.

Berson: Both the Senate and the House agree that the doughnut hole needs to be closed. That would be beneficial to retirees.
People in that doughnut hole can find it very difficult to afford their drugs. The Senate bill would reduce the out-of-pocket spending by creating a coverage gap discount program where seniors could buy drugs at lower cost.
The House bill would close the coverage gap over an eight-year period and provides for an initial discount in 2010-2011. As well, the administration wants to make generics more available. ... Industry agreements have extended the patent protection of branded drugs through minor changes in the formula or resulted in deals between branded pharma and generic makers that delayed generics from coming to market.

The FDA says it added its strongest warning today to the label of the widely used bloodthinner Plavix, Bristol-Myers’ best-selling drug, to help physicians treat patients correctly. But the warning could make doctors’ job more difficult.

Docs prescribe Plavix to reduce the risk of heart attacks, strokes and other serious heart problems. The drug prevents dangerous blood clots that can cause those conditions. As a growing number of studies has demonstrated, however, Plavix doesn’t work well in certain patients - those with a genetic variation that makes it difficult for them to metabolize the drug.

The FDA says between 2% and 14% of Plavix users don’t respond well to the drug and might benefit from alternative treatment. Hence the new so-called black-box warning.

Genetic testing could identify the poor responders. But most doctors aren’t well equipped to do genetic testing. They don’t have quick access to the tests. Even if they did, they might not have time in the cases of many patients to wait for results to come back.

What’s more, the FDA has approved only one genetic test, Roche’s AmpliChip, to look for the variation, but not specifically for determining treatment with Plavix. Many laboratories offer other tests, whose quality the FDA says doctors will have to assess before using. Doctors should make sure the tests are at least 98% accurate, FDA officials told reporters.

Christopher Cannon, a Harvard Medical School associate professor and editor-in-chief of Cardiosource, tells the WSJ’s Ron Winslow that heart-doctor associations will need to develop protocols for testing and treatment. The alternatives include increasing the dose of Plavix or switching to bloodthinner Prasugrel from Lilly and Daiichi Sankyo, but Cannon says neither has been tested for that purpose.

“Thus a real conundrum” for patients and their physicians, Cannon said. “I expect mass confusion in response to this FDA warning,” he added.

Plavix, which is also marketed by Sanofi Aventis, is the second-best selling drug world-wide with $8.6 billion in sales in 2008, according to IMS Health.

This is the transcript of part 1 of my podcast interview with Christus Health SVP/CIO George Conklin.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with George Conklin.  He is Senior Vice President and Chief Information Officer of Christus Health.  George, thanks for you time today.

George Conklin: You’re very welcome David.

Williams: What is the size and scope of Christus Health?

Conklin: Christus Health is a 44-hospital Catholic health care system based in Dallas, Texas.  We have hospitals in Texas, Louisiana, Arkansas, Oklahoma and New Mexico and seven facilities in northern Mexico.

Williams: What are your information technology capabilities?

Conklin: We have a large data center that we opened in November of 2008 in San Antonio, Texas and a backup for disaster recovery about 25 miles away.  We operate our main and mission critical systems out of that data center, but have a growing number of applications that we operate in the cloud, Humedica being one of those.  We have a smaller but growing data center in Monterey, Mexico for operation of our Mexican hospitals and as we extend further into Central and South America for those organizations as well.

Taking it up a layer, we connect over 380 different locations where Christus does business. They run the gamut from our 44 hospitals to doctors offices, clinics, home care agencies and a wide variety of other kinds of health care services that we operate.  Also –as a reflection of our three-part business strategy—we operate a large array of non-acute services and retail services.  These retail services are found in our hospitals right now but are beginning to move into shopping malls and other locations. We now also have a web presence; you can go to www.christushealth.org and branch off to commercial products that you could buy.  You could buy vitamins and lotions and things like that on our website as well.

The three-part strategy includes:  (1) drastically revamped acute care through a network of hospitals focused on delivering low cost high quality service, (2)  non acute and retail and (3) international.

Our IT strategy is to aggregate information across all of those different entities. We want to be able to bring just the right information back to the point of need.  So a physician treating you would be able to get just the right information to help me in my treatment of you.  If I were an administrator looking at the class of all the David Williams’ or class of all people with congestive heart failure, I would be able to look at the best ways of treating people. The objective is to move us toward our goal of being a low cost, high quality provider.

Williams: That sounds like a very well thought out strategy.  How close is it to being realized?  Is it in place today or is that more of a long term strategic vision?

Conklin: That’s a longer-term strategic vision.  Today, through our portals, a clinician could gain  access to George Conklin’s information from anywhere, but would have multiple log in’s and multiple systems to look at.  We are actively seeking a health information exchange engine to sit on top of all our systems.

We want it to do three things for us.

One is to present the information in a uniform fashion so you won’t have a Meditech system in one location that you’d have to learn how to deal with and a server system in another location that you’d have to deal with.  Instead, you would just have one way that you interact with the systems. So the first thing would be the presentation piece.

The second piece is the decision support piece. There really are no HIE products today that provide that decision support component. We’re working with vendors now to glean just the right information for the episode.  If you think about it, as health information exchanges begin to grow around the country, one of the big concerns among clinicians is being buried in information about David Williams and having to paw their way through all this extraneous information. They need to get to specific pieces of information. It’s important to have all that other information available, but there is also an awful lot of it that’s not going to be relevant to a particular care event that somehow or another we need to figure out how to pull apart.  So decision support in part would help to parse the information so just the right information is being brought to the clinical event.  But the second part of it is to really help a clinician make better clinical decisions based upon science, based upon the costs of different kinds of treatment, based upon the organizational protocols that have been set up for particular organizations like Christus Health.  So that’s the second component of that HIE architecture.

The third component of it is data aggregation for large analytical studies that let you determine the best ways of treating people with diabetes, COPD and so forth.  As a former clinician and psychologist myself, when I used to see patients in the emergency rooms, one of the questions I would ask is, “David, why are we here today versus yesterday?â€� One of the things that was driven home to me very early on in working in the community mental health movement is that there is a difference –and it’s not always obvious– between people who are sick and people who are ill.  Most of our treatment decisions are based upon bodies of data aggregated in hospitals. This is not necessarily the best body of data for me to keep you well in the community.  So part of our plan is to be able to integrate data across a very large delivery spectrum to be able to look at how we keep diabetics productive and happy in the community longer, not base our treatment protocols on patients who are in our hospitals.

Williams: Speaking of analytics, let’s discuss your work with Humedica. I’ve interviewed the CEO and some of the top staff there and they cite you as a key partner in the development and launch of what they’re doing.  Can you tell me a little bit about you work with Humedica?  What are the objectives? What benefits are you seeing?

Conklin: One of the principals in Humedica is a woman named A.G. Breitenstein. We have worked with A.G. in a number of different positions that she’s held over the years, every one of them having to do with managing large sets of information and deriving usable and actionable clinical or operational information from them. So when A.G. moved to Health Insight, the predecessor of Humedica, we worked with her on new products in development. We have been working with them over the last couple of years on the creation of the database and the analytical framework.

One of the reasons they wanted to work with us is that we did something back in the 2004 to 2006 time frame that many organizations probably wished they had done and are now going to have to move towards themselves. We undertook a massive information and clinical protocol standardization effort across Christus.  We had remarkable acceptance from management, clinical leadership and clinicians across the organization around the concept of moving toward significant standardization.  We undertook standardization of lots of clinical and business processes, ending up with literally tens of thousands of items of both clinical and operational information standardized across the organization.  When we came to Humedica our ability to be able to pull essentially normalized data out of our systems and provide it to them so that we could create very large data bases gave them an awful lot of information that they could very easily work with as they were developing and testing their methodologies.  We were peculiarly positioned because of those decisions that we made back in 2004 to 2006 and we continue to move forward with that model today.

We were able to establish a very rich clinical and operational database that let us easily marry a lot of information about patients with cardiovascular disease or diabetes, etc. across the millions of visits and hospitalizations that we see on an annual basis.  That gave Humedica a very large database to work with without having to go through a lot of normalization effort on the front end. It allowed them then to focus on producing analytics that were very useful to us.

As you are aware from your prior discussions with Humedica, there are effectively two products that they’ve got.  One of those is for retrospective analysis of information and the other is for near real-time or prospective analysis.  The retrospective analysis has been utilized by us over the last several months in pilots to provide clinical leadership with detailed information on an aggregate basis as well as at a physician level about the performance of physicians in different clinical areas. It allows us to go back in those regions where the system is being piloted to look at the low cost, high quality providers, learn what those providers are doing and then talk to the other providers in that area about what we’re seeing from those other low cost, high quality providers.

That is beginning to slowly move performance from timeworn ways that people have been doing things toward newer, better practices. It confirms what we’ve believed for a long time, which is that if we provide physicians with data about how they’re performing then their behavior will change in positive directions.

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There are some harsh words for Democrats trying to overhaul health care in the Washinton Post this morning.

Comprehensive health care has been lost. If it fails, as appears possible, Democrats will face the brunt of the electorate’s reaction. If it passes, however, Democrats will face a far greater calamitous reaction at the polls. Wishing, praying or pretending will not change these outcomes.

Such rhetoric is common coming from Republicans these days, but this is different. The broadside comes in an opinion piece from Patrick H. Caddell and Douglas E. Schoen, pollsters for the last two Democratic presidents, Jimmy Carter and Bill Clinton. The pollsters agree that health care needs to be retooled, but they say that horse has left the barn.

Health care is no longer a debate about the merits of specific initiatives. Since the spectacle of Christmas dealmaking to ensure passage of the Senate bill, the issue, in voters’ minds, has become less about health care than about the government and a political majority that will neither hear nor heed the will of the people.

Bottom line, write Schoen and Caddell: “Unless the Democrats fundamentally change their approach, they will produce not just a march of folly but also run the risk of unmitigated disaster in November.”

Illustration: Getty Images

Some wrinkles in the health-overhaul orchestrations are in the news this morning:

Washington Democrats are working on an idea to pair the health-care bill bill with another Democratic priority of increasing federal aid for college students. The notion isn’t a firm plan, but as Senate Budget Committee head Kent Conrad told the Washington Post, “I’d say yes, we’re leaning toward it.”

Mixing the health and education bills might seem a stretch, but Democratic backers figure it might give them a 2-for-1 legislative bang. Dems already plan to use the reconciliation process in the Senate to make fixes to the version of the health bill passed by the Senate on Christmas Eve.

Adding the education package to the reconciliation vote, which requires a simple majority for passage, could mean both pieces of legislation would clear the Senate without a filibuster. The overhaul of the student loan programs in the education bill is another of the Obama administration’s domestic priorities.

As for the health overhaul, Democrats remain vexed about how to handle abortion restrictions, but party leaders appear willing to write off the votes of a dozen or so antiabortion Dems in the House if need be, the New York Times reports. The House abortion foes want tougher language to ban using federal subsidies to pay for abortions than those contained in the current Senate legislation.

One compromise would be for the House foes to accept the Senate language initially and then tighten the provisions later. But doubts persist. “I’m not going to trust that [tougher language] is going to pass the House and Senate” after the original bill passes, said Dem Rep. Daniel Lipinski told the WSJ.

Just when health-care bills will be put to a congressional votes remains up in the air. Lawmakers haven’t seen the latest draft texts and the Congressional Budget Office hasn’t calculated estimated costs. A March 18 target, which President Obama had hoped for, isn’t workable at this point, everyone was saying yesterday.

But House leaders now want the vote to occur before a two-week spring break scheduled to start on March 26, the NYT said. More meetings by House Democrats are slated for today.

From a paper by Weinstein and Skinner (NEJM 2010):

“Moreover, there is considerable variation in health care expenditures and a weak or even negative association between spending and outcomes, such as mortality at the regional level and quality measures at the state level. This evidence has been interpreted to mean that cutting back on these putatively useless or harmful services would simultaneously reduce cost and improve health. In contrast, several cross-sectional studies that have shown positive associations between spending and outcomes have been interpreted to show that more spending leads to better outcomes.”

“A recent study using chart-review data from the 1994–1995 Cooperative Cardiovascular Project categorized “…hospitals as either high-adopting facilities or low-adopting facilities, according to their rates of use of aspirin, beta-blockers, and coronary reperfusion in the treatment of acute myocardial infarction. The researchers found that the high-adopting hospitals had consistently better rates of risk-adjusted survival, at no additional cost to Medicare. But after stratification according to the hospitals’ adoption rates, there was a positive but diminishing effect of spending on the health outcome (12-month survival)…The cost-effectiveness ratios at the margin were $95,000 per life-year or more but with slightly better returns for the hospitals that were slower to adopt cost-effective practices…”

“Another study showed that regions that had high rates of revascularization for patients with acute myocardial infarction received good health value for the expenditure on the intervention.  Despite this, there was essentially a zero association between spending and outcomes across regions. The explanation is that the high-revascularization areas were also less likely to use beta-blockers and aspirin for their patients.”

• Weinstein MC, Skinner JA (2010) “Comparative Effectiveness and Health Care Spending — Implications for Reform,” NEJM, ePub, January 6, 2010 (10.1056/NEJMsb0911104).

The Southern Colorado Tea Party rallied yesterday in Pueblo, voicing their opposition to the health care reform bills.  One of the protesters who came to the rally was Warren Abbate, who said “It’s time people took back the government.  Everything in Washington is wrong. The government is too big and arrogant. If I can’t afford health care, that’s my problem, not the government’s.”  Abbate is an 80 year old retiree, and is thus covered by Medicare.  But he said that private health insurance would provide better coverage.

I don’t know any more details about Mr. Abbate’s specific situation than what was included in the article about the rally.  I don’t know if he has chosen to carry a private Medigap policy or Medicare D for prescriptions.  But I wonder if he’s aware of just how much a private health insurance policy would cost if such a thing were available.

Individual health insurance is available until a person reaches age 65, but the prices increase dramatically with age; people in their 60s pay substantially higher premiums than people in their 30s.  Statistically, health care costs increase with age, and it would stand to reason that if people could continue buying their own health insurance past the age of 65, the prices would continue to climb rapidly.

Out of curiosity, I ran quotes for a perfectly healthy non-smoking, 64 year old male living in Pueblo.  The premiums for my hypothetical client ranged from $123/month for a bare-bones, $10,000 deductible policy with 50% coinsurance, all the way up to $1,788/month for a very comprehensive, 100% coverage HSA plan with a $1,200 deductible.  Most of the popular policies were in the $300 – $500/month range.

I’m not able to run quotes for an 80 year old, but obviously the premiums would be significantly higher for an 80 year old than for a 64 year old, if such policies existed.  Even if Mr. Abbate has chosen to have the very best Medigap and Medicare D coverage he can get, my guess is that his combined monthly premiums for his health insurance is a fraction of what it would cost if he were buying all of his health insurance from private carriers.  I wonder if he would still be saying “If I can’t afford health care, that’s my problem…” if his only option were to purchase his own policy at 80 years of age?

Individual health insurance is a great option for people who are healthy, and especially those who are relatively young.  For people who are self-employed, it’s a good alternative to higher-priced group of one policies, and it gives people the flexibility to pursue entrepreneurship without being tied to employer-sponsored health insurance.  But the price increases with age, and many early retirees find it a challenge to pay for health insurance during the years before they are eligible for Medicare.  My guess is that even if private individual policies could be purchased by people over the age of 65, very few people would take that option, simply because of the price.

We now return you to your regular programming.

Connecticut’s Quinnipiac University announced earlier this year that it wanted to open a medical school, beginning a push that will take until 2013 or 2014 to get the first med students in the door.

The new school would be located in several buildings that the university, located near New Haven, purchased in nearby North Haven from WellPoint’s Anthem unit for $32 million several years ago. Read more on the plans here.

Schools like Quinnipiac that want to grant MD degrees go through a lengthy process required by the Liaison Committee on Medical Education. The panel is made up of med-school officials, practicing docs, public members and med students. It currently has 132 fully accredited schools in the U.S. schools and 17 in Canada.

Seven new schools — two each in Michigan and New Jersey and one each in California, Florida and South Carolina — have reached applicant status with the committee, meaning they has gotten through the preliminaries and paid a $25,000 fee. Another, Hofstra University in New York, is currently the only one at the next step in the process when the first site visit by the LCME takes place,

Six schools now have preliminary accreditation, meaning they can recruit and accept students. This group now includes two more Florida schools and others from Michigan, Pennsylvania, Texas and Virginia.

One last level (no schools currently here), a few more hurdles like a final vote and at last — it’s accreditation time. For lists of the schools at different levels on the accreditation journey, see here.

Image: iStockphoto

Remember the 1980s and early 90s? That’s when HMOs successfully slowed or even reversed health care spending increases with tools such as prior authorization, gatekeepers, restrictive drug formularies, narrow networks and capitation. Employers were happy to save money and also didn’t mind that the HMOs took the blame when patients were unhappy. Then in the mid-90s a backlash against managed care began, leading to the dumbing down of managed care’s cost saving practices and the re-emergence of indemnity insurance by other names (e.g., POS plans). Not surprisingly, costs started rising fast again, a trend that has continued to the present day.

And yet the backlash against managed care continues. Health insurers are being beaten over the head by politicians and others. No doubt some of the criticism is justified, because there are plenty of abuses to be found. But the popular view that cracking down on insurers is going to solve the health care cost crisis is dangerously misguided. Bashing health plans gives others –especially hospitals, clinics, doctors, patients, employers, politicians and regulators– a free pass. The big drivers of health care premiums are volume of health care consumed and rising prices, which are not caused by health plans.

Even the debate about pre-existing conditions is not so straightforward. It’s considered a given at this point that health plans shouldn’t discriminate against people with pre-existing conditions. Yet the fact remains that pre-existing conditions drive up the cost of insuring an individual.

Contrast this situation with other areas of insurance. I am in the process of upgrading my disability insurance, and you can be certain the insurance company is taking steps to make sure I’m a good risk. That means asking medical and lifestyle questions and subjecting me to a physical examination that includes blood and urine tests. It’s the same thing with life insurance. Although it’s unfortunate for people in poor health, this system at least keeps premiums affordable for those at low risk.

Don’t get me wrong. I’d also like to see a ban on discrimination based on pre-existing conditions. But this does have to be coupled with mandated coverage in order to bring the whole population into the risk pool.

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Fast-growing spending on imaging tests in Massachusetts gives a closeup view to the many-sided question of whether improved technology is really worth the extra cost.

The facts, as laid out by the Boston Globe this morning: Spending on MRIs, mammograms, and other imaging tests for privately insured Massachusetts residents jumped 20%, or $214 million, between 2006 and 2008, according to consultants hired by the state. Doctors ordering more tests was one reason for the added spending.

Digital mammography was another prime driver as some insurers pay more for these breast-screening tests and hospitals have invested upward of $400,000 for such new machines, compared with $100,000 for earlier units. The digital technology is faster and can be used with electronic health records.

But there hasn’t been any evidence that digital mammograms hold a significant edge in detecting cancer in most women compared with older tests, the Globe says. It also turns out that more imaging tests these days are being done in hospitals, which charge more for the services than independent clinics.

“A scan done in a hospital is of no better quality and is not being read by a more qualified radiologist than one done in a freestanding clinic,’’ the paper quotes an official at insurer Harvard Pilgrim Health Care as saying. On the other side, the Globe writes that hospital officials believe

the stateÂ’s consultants overstated the role higher provider fees are playing in pushing up costs. And, they said, the increase in the number of scans has slowed significantly since 2008, as more insurers began requiring preauthorization for certain scans.

A company that manages radiology benefits for insurers also tells the Globe that makers of imaging equipment lobbied Congress for higher payments from Medicare to encourage service providers to buy the new technology and helping generate premium payments from private insurers for tests done with digital gear.

Photo: Associated Press

Comparative Effectiveness has been a hot topic in health services research. According to a recent article in the New England Journal of Medicine, “the American Recovery and Reinvestment Act of 2009 authorizes the expenditure of $1.1 billion to conduct research comparing ‘clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions.’”

Comparative effectiveness compares how effective various medical treatments improve health outcomes.  This sounds like the course we want to take.  Most policymakers laud the health benefits of comparative effectiveness research, but some people claim that comparative effectiveness research can also save cost.

This is most easily seen in the case where a treatment is completely ineffective.  If research can prove a treatment is ineffective, then insurers could save a lot of money by not covering this type of treatment.  This is especially true if the treatment is expensive.

However, comparative effectiveness treatment could also increase cost.  Assume that there are two treatment currently in use: Treatment A and Treatment B.  Let us say that treatment A costs $1,000 and has a 90% cure rate and Treatment B costs $10,000 and has a 95% cure rate.  According to comparative effectiveness research, we should always use Treatment B.  Yet this would significantly increase costs.

Most health economists argue that cost effectiveness research is provides a better way to improve health and decrease cost.  In the example above, should we cover Treatment B?  The answer is likely yes if this is a very serious disease (e.g., cancer) but likely not if the disease is less serious (e.g., the common cold).  Some readers may believe insurers should always cover Treatment B no matter what.  However, would you be willing to pay increased premiums that would occur if treatment B were covered?  Would you feel the same way if Treatment B cost $100,000?  or $10 million?  What if the cure rate was only 90.1%?

At some point, there must be a trade-off between cost and benefit.  Admittedly, these are very difficult decisions in practice, but because there are limited healthcare resources, we must ration care.  Yes, I said it, we must ration care.  I’ve said this before.  This rationing can take many forms: the scope of what your insurance company (or Medicare) will cover, waiting lines, or increased prices you must pay out of pocket for medical services.  The government wants to avoid making these tough choices because it is politically unpopular.  Politicians don’t want to be labelled  the sentator who “killed Grandma” or “instituted a death panel.”  But to truly decrease cost and improve quality, cost effectiveness rather than comparative effectiveness is the prescription we need.

Cost has been a major factor in the health care reform discussions from day one.  When it comes to health care, most people would rather have someone else pay for their care.  But we can’t all pass the cost onto someone else – eventually somebody has to foot the bill.  The way I see it, there are two issues:  One is fairness, and the other is value.

How can we most fairly spread the total cost of care for all Americans across the whole population?  Should sick people pay more than healthy people?  Should overweight people pay more than their slender neighbors?  Should a family with six children pay more than a family with one child?  Should older people pay more than younger people?  Should people with higher incomes pay more for their health care than lower income families?  These are the sort of questions that address the issue of how to fund our current high-priced health care.  And they are a huge part of the reform debate, including all the discussions about mandatory health insurance and guaranteed issue coverage.

But value in health care is another cost issue, and one that I don’t believe has been adequately addressed in the current health care reform bills.  Earlier this year, we had to call a plumber to have some work done in our bathroom.  He did a great job, and our total bill came to $165, including parts.  A week later, our son caught his finger in a door, ending up with a pretty severe cut.  We took him to the emergency room (unfortunately it happened after the lower-priced urgent care center had closed for the evening) where he had an x-ray and got three stitches.  We’ve started to get the EOBs from Humana, and so far the total amount that we’re expecting to be billed is over $1,400 (that’s after the network negotiated discounts, and there are likely more EOBs to follow).

We have an HSA qualified policy with a $5,000 deductible, so we’ll be paying the whole bill for our son’s finger ourselves.  But that’s not really the point.  Regardless of whether a bill is paid by the patient or by the health insurance company, we all need to be asking ourselves whether we’re really getting a good value for our money.  When the average household income in America is just over $50,000 a year, does it make sense for a cut that requires three stitches to cost more than $1,400?  Health care spending in the US is 16% of our GDP, which is dramatically out of proportion with what other countries spend.  And all of those dollars being spent on healthcare aren’t available to be spent on other things like education and quality food and clean energy.

Both the plumber who came to our house and the PA who stitched our son’s finger performed a very necessary service for us.  Both are highly skilled in their areas of expertise, and we’re grateful for the work that they did.  But was the work that the PA did ten times more valuable than that of the plumber?

Perhaps the question we should be asking is not who should be paying for healthcare, but rather, why in the world are we paying so much in the first place?  Health insurance premiums will continue to rise as long as health care costs do the same.  It won’t do any good to try to address premiums without first figuring out why we’re paying so much for our health care in the first place, and doing something about it.

Russell Hutchinson presents the 100th edition of the Cavalcade of Risk.

Here are some other links of interest

• German Ministry of Health considers a 20-30% cut in hospital beds.
• Best and worst health reform ideas according to a libertarian.
• The median salary change for faculty members in 2009-10 was 0 percent.
• Should nurses be able to facebook at work?
• Pharma advertising or public service announcement?
• Catchy title, but an irrelevant research question.
• Lessons of a $618,616 Death.

Chatswood Consulting hosts the 100th edition of the Cavalcade of Risk blog carnival. Enjoy!

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In part 1 of our podcast interview, Christus Health SVP/CIO George Conklin described describes how his 44-hospital system leverages IT to support its business. In part 2, he explains how organizational culture, psychology, technology and leadership interacted to enable the organization to achieve massive standardization of data and protocols.  That effort has allowed Christus to generate value from the scale of its information resources, for example through its partnership with Humedica.

When Christus Health came together several years ago, Conklin and his colleagues realized the time was not ripe for standardization. Regional leadership was protective of their individual approaches, and senior management chose not to resist. Instead, Christus initiated its 4 Directions to Excellence program emphasizing:

1. Clinical quality
2. Service quality (with measures of patient, physician, and employee satisfaction)
3. Business literacy
4. Community value

These four elements were tracked in a balanced scorecard, which led to subtle competition among the different parts of Christus and adoption of best practices, setting the ground work for standardization.

By the time the regional CEOs approached senior leadership with the request for a single IT system in 2004, they were ready to accept the idea of large-scale standardization, rather than being so protective of local autonomy.

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David Williams of Health Business Blog has written an interesting article about why states can’t drive health care reform.   I agree, and believe that in order to have meaningful change, it will need to take place on a federal level.  One of the issues that David addresses is the problem that occurs when a state enacts tough legislation and insurance companies simply choose to operate in states with more lenient regulations.  There are already a wide range of laws on the books pertaining to health care in each of the 50 states, and it is absolutely the case that insurance companies and health care providers will consider those regulations when deciding where to do business.   In Colorado, we have a wide range of options available for people seeking individual health insurance plans, but in NY, where individual policies are required to be guaranteed issue, there are only a handful of very expensive policies from which to choose.

We currently have 50 states with 50 different levels of health care regulation.  For people who are ill, some states are much better places to live than others.  State-driven health care reform could theoretically be expected to increase the populations of sick people in states with very patient-friendly laws, thus driving health care costs even higher in those areas.  No state is an island.

Since much of the health care reform debate comes down to money, I think David’s comment that “…the federal government has an easier time running large deficits than the states do.” is the most pertinent point of all.  Basically, the logistics of genuine health care reform could bankrupt many states.  It might run the federal government into a good deal of debt too, but the feds have more avenues for dealing with debt than the states do.

I feel fortunate to live in a state where we have a solid high risk pool (Cover Colorado) and lots of options for policies in both the individual and group market.  But I can’t help but think of people who live in states where there aren’t any health insurance policies available to people who are sick and not covered by an employer’s plan.  Or people who live in states where health insurance is guaranteed issue but not mandatory, and thus extremely expensive.  For them, health care reform on a state level has a long way to go, and might not happen at all.

David’s article was included in last week’s Health Wonk Review, hosted by Brad Wright at Wright On Health.

From the N.Y. Times:

The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.

In fact, the rate of vaginal birth after Caesarean (VBAC) is now below 10%.  Some doctors claim that VBACs risk tearing the mother’s scar tissue on her uterus, but others–including the profiled women on a Navajo reservation–successfully undergo multiple VBACs.  Why are the rates VBAC rates so low?

• Fears of malpractice
• Physicians make more money Caesarean rather than a vaginal birth
• Caesarean’s use fewer physician hours than vaginal births
• Fewer expected number of pregnancies
• Patient demand

Why are Caesarean rates so much lower on the Navajo reservation?  On the reservation, physicians are federally insured against malpractice, are paid a salary, and the use of midwives is much more common.  Additionally, Navajo “couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery.”

To see further evidence of how different physician compensation methods can alter surgery rates, see my own study in Health Economics.

Welcome to Grand Rounds 6:24. Regular readers know I provide a mix of health care wonkery, cheerleading of entrepreneurs, and light-hearted, humorous Grand Rounds. But this week’s batch of submissions is mostly in the pain and suffering category.

If you think I’m joking, read on.

Pain and suffering

Other Things Amanzi is profoundly affected by the death of a kidney transplant patient. The fellow walked into the hospital with the realistic hope of life without dialysis and departed on a cold morgue slate. Can’t win ‘em all, but that’s not much comfort in this case.

Dr. J’s HouseCalls was tempted to “employ extreme physical violence” when a minister said at a memorial service that her cousin was going to hell after his suicide. Twenty years later she’s not completely over it.

We don’t really know why the SeaWorld whale killed its dedicated trainer last month or why it wasn’t euthanized after that. ICSI Health Care Blog ties that observation to the public’s feelings about health reform.

Infertility is tragic. Using a branding iron to imprint pictures of sperm on someone’s skin don’t generally make things better, reports Dr. J’s Surgical Adventures.

If serious illness weren’t trouble enough, how about the guilt it brings to a marriage? The sick spouse feels guilty for ruining things by being sick while the healthy person feels guilty for being healthy and able to live a normal life. In Sickness and In Health explains.

Pain and its (possible) relief

The Game of Life (especially the Rite Aid version) is tedious. After collecting lots of tiny tokens, somehow there’s always just one missing for a fabulous prize. At least for Fibro World, that’s what fibromyalgia is like. Yet hope remains.

College rejection letters are coming, and Teen Health 411 has suggestions for coping. Hint: the magic word is empathy.

Got back pain? Exercise is the only thing that seems to work. From the Fitness Fixer.

How to Cope with Pain has a basic relaxation exercise for you.

Is that just a twisted ankle or does your kid need a trip to the ER for an x-ray? Ottawa Ankle rules were the most sensitive test in a recent study, according to Ankle Rules for Children.

Psychiatric problems

Psychiatry is floundering, reports the Cockroach Catcher. Diagnoses are becoming foggier, drugs less effective.

Perhaps one of these pills or pecans from the Examining Room of Dr. Charles will do the job.

Lockup Doc discusses the conditions under which a psychiatrist might discuss his private life. Example fitting our theme: when a psychiatrist and patient are both mourning the loss of a child.

Ready for the Freeze Phase change model? If so, Will Meek PhD is your man.

Is lack of time really the problem in doctor/patient communications? Mind The Gap has an opinion on that one.

Happy 5th birthday

It’s not all doom and gloom, folks.

Diabetes Mine reminisces about a Dr. Seuss “Fun With Diabetes” book she wrote back in March 2005.

That also happens to be when I launched the Health Business Blog, which I celebrated with a 5th anniversary edition last week.

This that and the other

A word of advice: don’t mess with EMS success. From Everyday EMS Tips.

InsureBlog pokes fun at a New York Times article that claims 22,000 people died in 2006 due to lack of health insurance. Clever satire –but honestly I would have preferred a critique of the IOM, Urban Institute and Families USA research the Times cited.

ACP Internist advises that the quality chasm is being crossed -albeit slowly.

Sniff test: device sniffs employees’ hands for soap residue to make sure they’re washing up in the hospital. Bedside monitor will light up if employee is good to go. From ACP Hospitalist.

The Office of Disease Prevention and Health Promotion (part of HHS) has launched the National Health Observances Toolkit, to be used to help engage the public in health promotion activities. Learn more at Highlight Health.

And now for something somewhat different

Hospitals and doctors are using social media such as Facebook and Twitter. Medicine and Technology reports on the topic from HIMSS. He’s hosting next week, so do him a favor and send submissions that are a little more chipper!

Share

Some estimates claim that one-quarter of life-time spending on medical care occurs in the last year of an individual’s life.  Conventional wisdom says this is inefficient, but a paper by Philipson, Becker, Goldman and Murphy (2010) disagrees.  Individuals at the end of their life place very high value on terminal medical care for the following reasons:

1. If resources have no value when dead, a self-interested individual would be willing to forego his entire wealth to extend his life.
2. The preservation of hope raises the value of life.  The authors claim that if a patient is given a death sentence in 6 months, he values those 6 months less than if he knew he would live after that.
3. The social value of terminal care is often greater than the private value.  Adult children (hopefully) places a high value on extending the life of their elderly parents.
4. The value of terminal care may be the same regardless of a patient’s quality of life.  QALY estimates of the value of life underestimate the utility the elderly receive from being alive, even in a very frail state.

Source: Philipson, Becker, Goldman and Murphy (2010) Terminal Care and The Value of Life Near Its End, NBER Working Paper #15649.

A new poll released last week shows that most Americans are in favor of health care reform (75%) but only a quarter of the people polled want to see a bill passed that is similar to what the House and Senate have already passed.  Nearly half of the respondents want congress to start over, and the other quarter want lawmakers to shift their focus away from health care reform all together.  Not surprisingly, the opinions differ sharply along political party lines.

My guess is that the people who want congress to stop working on health care reform are those who have great health insurance that is largely funded by an employer.  Or they may be very wealthy individuals who have little if any concerns about  paying for unexpected medical bills.

One of the biggest obstacles to public support of health care reform is all the different avenues by which Americans get their health insurance and health care.  People who live in towns with great public clinics that provide services based on a sliding fee scale might not be is such bad shape, even without health insurance.  People who have excellent employer-sponsored health insurance are also doing pretty well in terms of health care.  Even public health insurance varies from one state to another, with some states having much more restrictive limits on who qualifies for programs like Medicaid.  And the simple fact remains that most Americans get their health insurance from their employers, and are thus relatively insulated from the whole process of purchasing health insurance and dealing with problems like pre-existing conditions and medical underwriting.  In addition, rate increases on group plans are partially paid for by employers, which means that the impact of rate hikes in the group market isn’t felt as strongly by individual members as it is in the individual market.

The people who are hurting the most are those who purchase their own health insurance, and people who work for very small businesses that struggle every month to continue to pay the premiums to keep their policies in force.  These people make up a relatively small percentage of the population, and their voices are being drowned out by all the people who don’t have to deal with the issues being addressed by health care reform.

Last week’s seven hour health care summit was basically a rehash of the ideas that were tossed around throughout the last year of health care reform debate.  Neither party seems willing to negotiate much more in terms of the nitty gritty of the reform, and it’s looking like the Dems might try to use reconciliation to push through their reform bill.

The Republicans are saying that we need to start again, scrap the whole thing, and take “baby steps” towards a solution.  But I’m skeptical as to how that would work.  For the most part, congress in 2010 is made up of the same people that were there in 2009 (with some notable exceptions, like John Murtha and Ted Kennedy).  I find it hard to believe that starting again would result in a significantly different bill this time around.  Wouldn’t it just be a waste of another year of lawmaking efforts?  It’s unlikely that the people who came up with the first bill would be willing to make major changes if they did it again this year… we’ve seen resistance to compromise from both sides of the aisle over and over during this debate, including during the bipartisan summit last week.

As for the idea of “baby steps”, I don’t really understand the benefit that would be created by going slowly.  The current House and Senate bills could be considered baby steps as they are, given that most of their major provisions wouldn’t take effect for another three years.  For people who are uninsured and struggling to pay for health care (or not receiving any at all), I imagine that the prospect of a three year wait seems like an eternity already.

A lot of the provisions in the current bill make sense:  no pre-existing condition exclusions, no policy rescissions, subsidies to help people pay for health insurance, and a strong mandate requiring everyone to carry health insurance.  Americans are generally in favor of the idea of doing away with pre-existing conditions exclusions and policy rescissions, but tend to balk at the idea of requiring everyone to carry health insurance.  But I doubt that the former are possible without the latter… unless we all want to pay much higher health insurance premiums.

If we started over, do we really think that the same group of lawmakers would come up with a dramatically different bill the second time around?

 “Come on down!� Those are awfully familiar words to any “Price is Right� guru. Ever notice how the items being bid on are all brand names? It’s part of “branding,� and it works well if you’re targeting a fan of the CBS hit television show, even post-Bob Barker!

There’s a time and a place for brand names. I choose Kraft Macaroni and Cheese over the store brand, it’s my personal preference. Why? In my opinion, Kraft has a better product, and the difference is definitely noticeable. (Yes, it is the cheesiest!) I could save about $25 a year by choosing the store brand, which adds up to about $1,250 over my lifetime.

Now, this is crazy. The average person has one prescription per month, and the cost of the brand name prescription, on average, is $100.00. Let’s say from age 45 to age 68, a person spends this amount per month on the same brand name prescription. That’s $27,600! What? $27,600! Sorry, it was just SO worth repeating!

Now, let’s take this same person and factor in medtipster.com, where the same prescription is available in a generic form (which is an exact replica of the brand name) for only $4.00 per month. Now we’re talking! That’s just $1,104.00 over 23 years. While I’m sure you can do the math, basically the difference is, well, a new Honda Civic Hybrid, or two Kia Rios!

So you see, we’re not talking mac’n cheese any more. While “The Price is Right� for some purchases, it’s better to “come on down� on prescription drug spending.

Guest post by Tylar Masters, Marketing & Communications, Medtipster.com

About Medtipster: Medtipster provides consumers with a solution to the rising cost of health  care. Using Medtipster’s proprietary technology, consumers simply type in their drug name, dosage and zip code, and instantly find their prescription drugs available on discount generic programs, located right in their own neighborhoods. Many of these drugs are available for $4 or less.

Increasing popularity of high deductible health plans

The most recent National Health Interview Survey (NHIS) from the Center for Disease Control finds that now 22.7% of the under-65 population is in "high deductible" health plans. This is up from 19.4% just one year ago. This includes 6.4% of the population with a Health Savings Account, up from 5.2% last year. It does not separate out HRAs from other people with stand-alone high deductible plans. The report also mentions that fully one-half of the individual market now has high deductible health coverage.

SOURCE: Center for Disease Control

With health care prices rising, wait lists growing longer, and benefits decreasing, it makes more sense than ever to take more responsibility to help manage you and your family’s health. With the help of the internet, do-it-yourself health is growing at an increasing rate.

If you are ready to take charge of your own health, take a look at these 100 useful tools for mananging your health care. Although they don’t substitute for a live doctor, they can be immensely helpful in getting information, preparing for a visit, and even finding a medical provider. This is a excellent collection of useful resources consumers can use and the 100 tools are organized into several categories:

• Information on alternative and traditional health care treatment options
• Useful information on supplements
• Symptom checkers and online quizzes to point you in the right direction
• First-aid and safety tools
• Consumer quizzes on health related topics
• Personal health record resources and tools
• Drug information tools Resources to learn more about health care
• Tools to find a doctor, specialist or hospital

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.

 

We love sharing tips on how consumers can save money on health care costs.   When it comes to lab tests, most consumers have their lab tests done through their doctors. For consumers that want to save money and time, online lab testing is an affordable way to have your lab tests done. Consumer online lab tests can be a convenient and cost-effective way to have the same lab tests done that your doctor orders --- while saving money on these tests. To use these online lab websites, consumers select a specific test(s), enter their zip code to locate a blood draw center in their neighborhood, and order the test online using their credit card. Depending on the consumer’s health plan, consumers might be reimbursed for this service. Be sure to check with your health plan for specific details. I’d like to introduce you to Personalabs.com, a direct-to-consumer lab test website.

PERSONALABSâ„¢ was founded in Aug 2006 to provide consumers with direct access to the same blood tests available from their doctor. No office visit is required, there is no medical record and their tests are offered at a lower cost. Their focus is to empower consumers by giving them the tools to make informed decisions about their health and wellness. They provide the same blood tests that are available through your doctor, including STD tests, health tests and drug tests, without waiting for a doctors' appointment and without the high costs. Online lab test sites make it very easy for consumers to get tested for a variety of health concerns.

The next time you need a routine lab test, I strongly recommend you consider online lab test sites. Consumers are invited to visit Personalabs.com and save 5% on their lab tests by using discount code “AD2009�.

An article in today’s CBS Moneywatch.com reviews diagnostics tests, their costs, purpose, concerns and if then test is worth getting.   If you are considering getting a non-emergency MRI, mammogram, CT scan, or nuclear scan, be sure to read this article.  If you want to learn more about prices for these diagnostic tests, you can search the Outofpocket.com directory to find true prices for these services.

From MRIs to Mammograms: Which Tests Do You Really Need?

Chalk it up as one more symptom of our broken health-care system: Americans waste more than $250 billion per year on unnecessary medical tests and treatments, according to a Thomson Reuters health-care analytics report. Often, doctors order expensive, high-tech tests to rule out unlikely possibilities, reassure worried patients, or as a CYA strategy against a possible lawsuit. An American Journal of Preventive Medicine study found that in 43 percent of cases where healthy people went in for routine checkups, doctors ordered an X-ray, electrocardiogram, or urinalysis. So how can you be sure you’re not wasting your money on medical tests you don’t really need?

Unnecessary medical tests don’t just take money out of your pocket. They can expose you to radiation, cause mental stress, and kill a day or more. Not to mention their cumulative effect: ever-climbing insurance premiums.

MoneyWatch wanted to find out whether five commonly prescribed tests are worth getting: mammograms, CT scans, PSA prostate screening tests, nuclear heart scans and MRIs for lower back pain. So we talked to experts in preventative and family medicine and pored through the latest research about the risks and benefits of these tests, which can cost up to $2,000 or more a pop. What we found may surprise you.

Of course decisions about medical care are intensely personal, and everyone’s circumstances are slightly different. If there’s a key takeaway it’s this: Medical tests are not analogous to checking your car’s tire pressure. Sure there may be benefits, but there can also be negative consequences. Be sure to educate yourself on the downside.

CT Scan

• Purpose: Non-invasive and painless, doctors use them to get detailed images of everything from cancerous tumors to signs of heart disease to bone injuries. You lie on an exam table that slides in and out of a machine. More than 70 million CT scans are done annually; 23 times the number in 1980, according to the Radiological Society of North America.
• Cost: Varies widely; average price is $1,150 for a brain CT scan, $1,800 for a chest CT scan and $2,175 for an abdominal CT Scan
• Concerns: Researchers are increasingly fearful that the scans’ radiation could lead to increased cancer risk and say that safer tests such as an ultrasound can sometimes do the job. Then, there’s the danger of medical error. Last August, 206 patients at Cedars-Sinai Medical Center in Los Angeles accidentally received eight times the normal amount of radiation during their CT scans. “A single CT scan for an isolated problem I’m not so concerned about. It’s when patients keep coming back for repeated exams that cumulative radiation starts to add up,â€� says Dr. Aaron Sodickson, assistant professor of radiology at Harvard Medical School.
• Worth getting? If your doctor orders a non-emergency CT scan and you’ve already had at least one previously, “ask your doctor if there are alternative tests that can be done,â€� says Greg Morrison, chief operating officer of the American Society of Radiologic Technologists. If you will undergo the test, first ensure that the facility is accredited by the American College of Radiology and that technicians follow the ALARA (As Low as Reasonably Achievable) protocol, so you’ll receive the lowest possible dose of radiation.

PSA Prostate Cancer Test

• Purpose: Doctors encourage men to get this simple blood lab test every year to help them avoid the second leading cause of death among U.S. males. But the PSA, or prostate specific antigen test, may do more harm than good.
• Cost: About $45; up to $1,500 if the test leads to a biopsy
• Concerns: The American Cancer Society does not support routine testing for prostate cancer, because of the risk of over diagnosis and overtreatment. Studies recently published in the New England Journal of Medicine found that PSA screening does find more prostate cancer, but the early detection does not translate into lives saved. For every man whose life is saved by early detection of prostate cancer, 48 others will undergo unnecessary treatment with possible side effects including impotence and incontinence.
• Worth getting? Discuss your options with your doctor. Some men opt for regular PSA screenings, but not to have surgery or radiation therapy unless an aggressive cancer is detected.

Nuclear Heart Scan

• Purpose: Doctors usually order these two- to four-hour tests after patients have had unexplained chest pain or pain brought on by exercise. The scans are designed to help detect narrowing of the arteries, damaged heart muscle, or to evaluate how well your heart is pumping blood. After a radioactive ‘tracer’ is injected into your veins, you take a stress test, walking on a treadmill or riding a stationary bike at increasing speeds. Then photographs are taken, showing your heart after strenuous exercise.
• Cost: About $2,000
• Concerns: Although this type of imaging can be useful for diagnosing heart disease, it’s overused. A pilot study of 3,035 scans for the American College of Cardiology (funded by insurers and cardiology groups) found that about 18 percent of the nuclear heart scans were done unnecessarily; another 16 percent were ambiguous.
• Worth getting? Ask your doctor whether an alternative test is available, such as a stress echocardiogram, which does not involve exposure to radiation and costs about $1,000. Discuss the amount of radiation you’ve been exposed to in the past to determine whether you may want to avoid future radiation, when possible.

Lower-Back MRI

• Purpose: A spinal magnetic resonance imaging (MRI) test can find changes in the spine and other tissues, infections, herniated discs, and tumors without using radiation. You typically lie on a moveable table that slides into a tube surrounded by a magnet. Newer standing, or open, MRI machines are also available.
• Cost: About $2,000
• Concerns: MRIs can show every bump and lump, which may lead to procedures causing more harm than good. The Health Affairs journal found that the increasing availability of MRI is linked to an increase in surgery for lower back pain even though symptoms for most back pain sufferers often resolve themselves without invasive surgery. The researchers theorized that doctors ordering the MRIs have a tendency to find something to blame in the resulting images.
• Worth getting? Experts say that if you have lower back pain, wait at least a month before submitting to an MRI. “The main reason you’d have an MRI of your lower back is if you’re going to have surgery,â€� says Dr. Daniel Merenstein, Assistant Professor and Director of Research in Family Medicine at Georgetown University Medical Center. “But for routine low back pain, surgery has not been shown to be any better than Motrin or other non-steroidal anti-inflammatory drugs or acupuncture.â€�

Mammogram

• Purpose: The 10-minute X-ray procedure can be done for breast-cancer screening purposes in the absence of symptoms or for diagnosis purposes after a doctor detects a change in a woman’s breast.
• Cost: About $125
• Concerns: For years, women were advised to have routine screening mammograms every year or two starting at age 40. Last fall, the U.S. Preventative Services Task Force recommended less routine screening, concerned that mammograms on women in their 40s yield a high number of false positives. For women without risk factors, such as a history of breast cancer among close relatives, the panel now recommends biennial screenings starting at 50 and until age 74.
• Worth getting? Although the panel advises women in their 40s without significant risk factors to discuss the usefulness of a mammogram with their doctors, leading breast cancer experts, including American Cancer Society and Susan G. Komen for the Cure, still strongly recommend women get screening mammograms beginning in their 40s. “The American Cancer Society acknowledges the limitations of mammography [but] overwhelmingly believe[s] the benefits of screening women 40 to 49 outweigh its limitations,â€� Dr. Otis Brawley, chief medical officer of the American Cancer Society said, in a statement. “We believe the evidence does show there is survival benefit for women who get screening in their 40s, although we acknowledge that benefit is not great,â€� says Susan Brown, director of health education for Susan G. Komen for the Cure. So until the medical community reaches a consensus, it seems best to get the mammogram.

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.