Idea #262 for November 7th, 2009: Left Out in The Cold or The Importance Of Medical Insurance For Children

With the direction of healthcare legislation still being fought over in Congress, one thing remains clear. Children in the US who do not have medical insurance coverage are at a disadvantage when it comes to quality of healthcare. Uninsured children with trauma injuries are three times as likely to die than children who do have insurance. This setup is inherently unjust, and Congress must take steps to rectify this problem for their legislation to be considered successful.

Researchers have a few hypotheses as to why uninsured children are much more likely to die from trauma. Without insurance, trauma patients are sometimes transferred from one hospital to another, which eats up valuable time that could be used to treat them. Also, fewer diagnostic tests may be ordered for un- or under-insured children, which can prevent an accurate diagnosis from being quickly ascertained. No matter the true reasons behind it, the statistic itself is alarming. The American public may have objections to universal healthcare, but those objections should end when it comes down to coverage for children — a population that has no control over whether or not it has healthcare insurance.

Read more about this statistic in the news here.

Idea #234 for October 10th, 2009: Abuse of Power or Some Domestic Abuse Victims Struggle to Get Health Insurance

We’ve all heard stories about people being unjustly denied health coverage due to pre-existing conditions, but this story is particularly egregious. A New Mexico woman was denied a policy based on medication and counseling she received after being assaulted by her ex-husband. The insurer claimed she was at high-risk of being admitted to an emergency department in the future. And as bad as that scenario sounds, eight states still allow insurers to use abuse as a legitimate reason for denying coverage.

A 1994 survey found that 8 of the 16 largest insurers weighed domestic abuse history as a factor when deciding on whether to allow a person to sign-up for their plans. While they may not explicitly ask a person about their history of domestic abuse, insurance companies have other ways to find answers. They can look for trends of abuse in medical records, or even scour news articles for mention of abuse and use that to deny coverage. As a result, women in those 8 states may be less likely to speak frankly about abuse with their doctors, considering that information might hurt their chances of procuring coverage down the line.

Attempts to fix this at the federal level have been unsuccessful up to now. Even as recently as 2006, a proposed bill to change the law nation-wide failed in Senate committee. We need legislation to change this, so that victims of domestic abuse aren’t discriminated against when trying to get healthcare coverage in the eight states where that practice is permitted.

Read more about this story from MSNBC.

Idea #233 for October 9th, 2009: Michelle’s Law or Keeping Students Covered During Illness

No college student should be forced into the decision of staying in school or taking care of their health. Unfortunately, health plans have had the right to drop students from their parents plans unless a full load of courses were being met per semester. For students who became seriously ill, that meant either continuing to be a full-time student while battling the illness, or taking a break from school and forgoing health insurance. But a new federal law taking effect today will change the rules so that students won’t have to make that choice anymore.

The law is called “Michelle’s Law,” named after the college student who was forced to study full time to avoid losing health coverage while battling (and eventually succumbing to) colon cancer. It will allow dependents to take up to a year off school while still maintaining health coverage. Thousands of college students across the country are expected to benefit from it. It’s a great idea, and it’s a little surprising we’ve gone on this long without having a sensible law like this in place.

Read more about this news from the AP.

Idea #190 for August 27th, 2009: Sticking To The Plan or Financial Incentives for Prescription Refills

Large insurance company UnitedHealth is making a move that will benefit both patients and drug makers. The company will soon offer $20 co-pay discounts to patient who adhere to prescription regimens. Patients who refill a prescription within 30 days after the prescription ends will be eligible for the discount. Adhering to drug regimens is vital to maintaining patient health and lowering costs in healthcare associated with complications from non-adherence. This program will provide some financial incentive to patients who may not otherwise refill their prescriptions.

UnitedHealth isn’t necessarily doing this out of the goodness of their heart either. At least a portion of the $20 discount will be covered by drug companies, who will obviously benefit from higher rates of prescription refills. This plan applies to only certain drugs, including antidepressants and asthma drugs, which normally have co-pays of $50. So patients will only have to pay $30 for refills of those drugs under this plan.

One thing that this program does not account for is the fact that many patients stop taking prescriptions for reasons other than money. For instance a patient may feel “cured” and no longer desire a certain medication. Also, side-effects of some drugs may steer patients away from adhering to the regimen. For those patients, this program will not increase adherence. But for those who find it difficult to afford the high co-pays associated with many drugs, the UnitedHealth drug discounts will be a great help.

Read more about the program in the Wall St Journal.

Idea #127 for June 25th, 2009: Out-Of-Network Ripoff or Insurers Using Bad Data

Yesterday I wrote about a pharmaceutical industry practice that is potentially costing Americans billions of dollars. Now Congressional investigators have brought to light an issue involving insurance companies that has also cost Americans billions. The issue: two-thirds of health insurance companies used an incorrect database that resulted in patients being overcharged for out-of-network care, which has totaled in the billions of dollars.

When patients go out-of-network, insurers generally pay a percentage of the “customary” rate, but the majority of them were basing these rates off faulty databases. The databases in question are owned by Ingenix Inc., which is a part of UnitedHealth Group Inc, a large insurance company. Ingenix is accused of altering the data used to calculate those customary rates, thus allowing insurers to underpay, and forcing patients to pay more than they should. Earlier this year, Ingenix settled with the NY attorney general for underpaying hospitals and doctors for out-of-network care. There’s an overall lack of transparency that leads to this type of activity, and hopefully more legal action, like that of the NY attorney general’s office, will bring other schemes to light.

See coverage in the NY Times, Wall St Journal, and Washington Post.

Idea #122 for June 20th, 2009: Congratulations, Now Don’t Get Sick or Post-Graduate Health Insurance

Today, getting handed a shiny new college diploma does not guarantee placement in a job. Employers will hire about 22% fewer grads this year than last. On top of that, fewer companies are offering health coverage to workers this year, due to grim economic conditions. Once their college health plan runs out, graduates are on their own as far as insurance is concerned. People in their twenties are the least likely demographic to have health insurance, with only about 70% of them covered. And about 34% of recent graduates lack insurance at some point during their first year after leaving school.

Young adults may feel invincible, but catastrophic illness or injury could occur at any time. Consider this: in 2007, medical expenses were a factor in 62% of bankruptcies filed that year. It’s too big of a gamble for people who can afford insurance to forgo it. Financial issues aside, people without insurance are also less likely to get preventive care, so smaller health issues may become larger concerns as time passes.

Graduates have a few options to be aware of. They may have the option of extending their coverage under their school’s health plan for a period after graduation. For students who were covered under their parents’ plans, the COBRA program will allow them to continue coverage for a few years, if the subscriber continues to pay the premiums out of pocket. Also, there are low-cost alternatives available for purchase, but many have deductibles and are good for catastrophic care only. Whatever route grads take, they should be aware of the dire consequences that forgoing insurance for any period of time can have.

See these two articles from the LA Times on the matter.

Idea #103 for June 1st, 2009: Health in the Heartland or Improving Rural Mental Health

Rural populations experience mental health issues just like any other population, but mental health care in rural areas is lagging far behind the care in other communities. Incidence of major depression and suicide among teens is higher in rural populations than in urban ones. There is a glaring lack of mental health services available to those populations, though. Of the approximately 1,700 federally-designated mental health professional shortage areas, over 85% are rural. The National Advisory Committee on Rural Health reported that there entire counties in rural areas that lack any psychiatrists, psychologists, or social workers.

On top of sparse availability of providers, rural populations also suffer from inadequate or non-existent health insurance coverage. Workers in these areas are often self-employed or part of small businesses, and as a result only 61% of the people are insured through their employers, compared to 72% in urban areas. There are a few ways to help fix these problems. For one, increased adoption of telemedicine can make it easier to reach patients in sparsely populated areas. Federal funds for improving rural broadband access would be needed to be spent first, though. Also, as part of larger health care reform legislation there should be an effort to provide insurance options that include mental health coverage for rural workers, who are all too often left without the benefit packages that their urban counterparts enjoy.

Read the report on the issue here (PDF) and see two news stories here and here.

Idea #56 for April 15th, 2009: You Can’t Afford to Neglect Diabetes or The Economy and Diabetes Care

The ripples from the global economic crisis are reaching many areas outside the world of finance, including healthcare. People are losing their jobs, and consequently, their benefit packages. In fact, 3.7 million Americans have lost their insurance since the crisis began. Even in cases where employees were not insured in the first place, the recession has now made it more difficult for them to pay for healthcare out of pocket. Because of this, patients have been cutting back on health spending.

The Associated Press reports that the recession has led to diabetes sufferers increasingly neglecting their illness since the economy faltered last fall. Close to 2 million new cases of diabetes are diagnosed each year, yet sales of diabetes drugs and devices for monitoring the disease have dropped recently. Meanwhile, the average co-pay of an office visit has risen in the past decade, making seeing a doctor more pricey even for the insured. Emergency rooms are now seeing more patients experiencing complications from untreated diabetes.

While ignoring or delaying treatment for diabetes might save money in the short term, the effects of the disease will be costly down the road. Diabetes can lead to blindness, neuropathy and amputations, and even death, if not monitored and treated correctly. The recession doesn’t have to mean you are stuck without treatment options. For those who can afford it, enrolling in the federal COBRA program allows the recently unemployed to continue their employee health insurance for up to three years. Also, low-income patients can qualify for discounted clinic visits and prescription assistance programs.

Read more stories about the economy and its effect on diabetes from: the LA Times, Associated Press, and a Wisconsin local news site.

Idea #47 for April 6th, 2009: It Pays to be Fit or Employee Incentives for Healthy Living

Many Americans struggle with health problems, and many employers struggle to pay insurance premiums for their workforce. It stands to reason that improvements in the health of workers would benefit not just themselves, but also their employers. For that reason, a number of companies are making efforts to improve employee wellness, and in some cases are offering rewards for participation in wellness programs.

Targeting obesity can have substantial effects on healthcare costs, as it is associated with other diseases like high blood pressure, high cholesterol, and diabetes. Similarly, smoking cessation can also drastically lower the occurrence of health problems. Companies are increasingly implementing workplace wellness programs, which may include education, screening, and interventions to keep employees and their families healthier. Employers that have started such programs have seen their healthcare costs drop 26%, according to the CDC.

But sometimes people need prodding to make lifestyle changes. Accordingly, companies are seeing employee participation in wellness programs increasing when incentives are offered, says one study’s findings. Incentives usually include rewards like gift cards for reaching certain wellness goals.

Aside from lower healthcare premiums, employers can expect a corresponding increase in job satisfaction and otherwise positive employee attitude about their job, as well as fewer missed days. This is a win-win situation. Given proper incentive, workers will take steps to improve their health, saving money for the company — and most importantly — employees’ lives.

To read more about wellness programs, see this LA Times article, and this press release from Humana.

Idea #10 for February 28th, 2009: The Rate Debate or I Have to Wait How Long For My Bill?

Imagine for a moment going to a restaurant that charges a small cover charge, perhaps $5 or $10, where the menu does not list prices but cryptically says that your dinner will probably not cost less than $50. Now imagine you order, complete your meal and upon inquiring for the bill, the waiter politely informs you that he doesn’t know how much your meal will cost and will get back to you in 1-12 weeks. Sounds ridiculous, doesn’t it? And yet that is exactly the system we have devised for taking care of our health care bills. Nobody can tell you with any certainty how much something will cost before or immediately after it is done. The opaqueness of these transactions dramatically inflates the cost of everything, severely limits patient choice among competing practices and adds tremendous difficulty in really understanding medical costs.

How do we solve it? Well that does get a little complicated — because of insurance policy and health IT — but by no means impossible. Two future posts will discuss tiered billing and retail medicine that would go a long way to solving the problem, but in this post I suggest regulation. No practice should be able to perform a service without providing a written estimate as to exactly what it will cost, or a clear time-based hourly rate. This is the standard we hold all other professional services to, and a very reasonable one at that.

Already I can hear providers saying this is impossible because they don’t know how much they will get from the insurance companies ahead of time; that is true. To solve that will probably take another post, but to put it briefly, the specific rate table on a code-by-code and diagnosis-by-diagnosis basis (CPT and ICD codes for the technical folks) between you, your doctor and your insurance need to be made readily available in a public and electronically-understood format (like Excel, etc). That way, different combinations can be compared and you’d know exactly what to expect. Insurance companies are loath to provide this information; they hold it as a closely vested trade secret. But just as we would ridicule a restaurant or mechanic who tried the same tactic, we need to ridicule these parties as well. The time has come for transparency, and only strong regulation will make it happen.

For a similar take on the issue, see: http://www.pbs.org/nbr/site/onair/transcripts/090801c/