The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

*********

It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

*********
The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

How to Pick Good Health Insurance - Your Life Depends on It.

Unless your doctor is a policy expert, in healthcare administration, a researcher, an author or blogger, I seriously doubt he will be reviewing an important report card that helps you pick the best health insurance plan that keeps you healthy.  Published annually by the National Committee for Quality Assurance (NCQA), this year's report card ranks 227 health plans across the country on their ability to keep you healthy and well, treat you quickly, and how patients feel about their insurance coverage.

Because unlike banking or airlines where there is not much difference in ATM machines or planes, there is a big difference in whether a health insurance plan helps in keeping its enrollees healthy.  Do children get their vaccinations?  Do healthy mothers get screened for breast cancer or cervical cancer with mammograms and pap smears respectively?  Do kids only get antibiotics appropriately for strep throat and not overtreated and unnecessarily when they have a viral illness or cold?  Are adults over 50 screened for colon cancer (something Dr. Oz can relate to).

You are incredibly busy living life.  Your health plan should proactively works with you and remind you to do the right thing?  It also helps doctors do the right thing.   

The NCQA report has been part of the US News and World Report best health plans over the past few years and will now be incorporated as part of Consumer Reports.

Be smart.  Be wise this year.  Trying to pick a health insurance plan seems easy.  They are all the same, right?  Simply look at the price.

No.

This is different.

This isn't auto insurance.  This is your health.  You want the best.  Choose wisely because your life and those of your family depend on it.

Picking the Best Health Insurance Plan - Open Enrollment. Choose Wisely.

It's that time of year again when many Americans have the opportunity to choose their insurance plan for the year. Open enrollment.

Most of us approach the time with indifference, dread, boredom, and often with a flick of a wrist, sign some papers and move on to more important things.

We would be wrong. All insurance plans are NOT created equal. Some are far better than others in keep you healthy and well even though on the surface they appear the same. Research consistently shows that within the US about 100,000 Americans die prematurely because they didn't have the basic things done like blood pressure, cholesterol control, vaccinations, or cancer screenings like mammograms.

The stunning fact? They all had health insurance.

Had they received care from the health insurance plans rated in the top 10 percent in the nation, they would be alive today.

It wasn't that the top 10 percent had the "best" hospitals or "best" doctors, but that insurance plans used their dollars to ensure that their enrollees got the right care that every medical student knows about during training. People over 65 years old should get a pneumovax vaccine to prevent 23 varieties of bacterial pneumonia. Ideally blood pressure should be controlled to less than 140 / 90 or in some cases even less then 130 / 80.

Somehow, this doesn't occur outside the academic classroom. Studies note that Americans only get a little more than half of the recommended treatments and preventive testing noted by organizations like the American Heart Association, American Cancer Society, and doctor groups like the American Academy of Family Physicians.

Result? People dying sooner than necessary, not because they didn't have access to the latest medication or imaging test, but because they didn't choose a health insurance plan focused on keeping them healthy.

So during open enrollment, make sure you choose wisely. There are plenty of places to research to help guide your decision.

In California, the Office of the Patient Advocate rates all of the HMO plans. Note the wide range of ratings from 2 stars to 4 stars. If you are going to spend a lot of money on health insurance to stay healthy and well, why would you chose a plan that is lower ranked? PPO plan ratings will occur in 2010.

For others, the National Committee for Quality Assurance has an excellent report card system as well ranking Commercial programs (health insurance companies), Medicare, and Medicaid programs. Fortune 500 companies use these reports to determine which plans to offer their employees. So perhaps the decision of offering you the best health insurance plan has been made for you already!

100,000 Americans with health insurance died prematurely because they didn't choose wisely. If you have a choice, then make an educated one so more likely than not you will be here another year to spend with family and friends.

Regulation Increases Health Insurance Costs. California Cheaper than New York.

I recently tried to help a relative purchase individual health insurance. He is in his 20s and lives in New York City. His current job does not provide health insurance benefits. He is healthy, does not smoke, and unfortunately since he is a college graduate he no longer qualifies for health insurance under his parents plan.

So naturally he asked me for help. What is absolutely shocking is how health insurance premiums very dramatically between the states. Using www.ehealthinsurance.com, I punched in his date of birth, smoking status, and ZIP code. He only had 12 choices of health insurance coverage with the least expensive being offered by Empire Blue Cross and Blue Shield at $151 per month and this is just for and indemnity plan.

A more comprehensive health insurance plan and the least expensive was $310 per month. This was being offered by Atlantis health plan which is a regional health plan, essentially restricted to the people of New York city. Because this insurance plan is so small, unfortunately, there isn't a lot of information externally about the quality of care delivered. The benefits however was that the co-pays were reasonable at $20 and there was no deductible. The down side is there is no prescription drug coverage. For that option it would be an additional $46 per month.

The next option, was offered by Oxford health plans. For a mere $372 per month, my relative could get a PPO plan but would have a $2850 deductible that would need to be met before health insurance kicked in. If there is any blessing in disguise, then it is that this program is attached to health savings account also known as an HSA. This is where people can defer money tax free, invest tax free, and spend tax free on qualified medical expenses.

If my relative moved to San Francisco, his health insurance rates will be far better with better options. Given the same information, he would have 115 choices with the least expensive being offered by Blue Shield of California at $52 per month, PPO plan with a $2900 deductible, 40% coinsurance, and $40 office visits. The next offering was from Aetna at $61 per month, PPO plan with a $5,000 deductible, 30% coinsurance, and $40 office visit. The first plan offers prescription drug coverage for generic medications, but not brand name. The latter covers both with generic medications at $15 and brand-name at $35, and those brand names nonpreferred list must meet a $500 deductible for medications before paying $50 per prescription.

Kaiser Permanente's least expensive offering was at $141 per month for a $1500 deductible, $30 office visit.

Why is this important? Although we live in the same country, and one could argue that the cost of living in San Francisco and in New York City are comparable, health insurance premiums vary wildly. This is most likely due to state regulations. Both New York and New Jersey have some of the most expensive health insurance plans in the nation. What if people in New York could get coverage at rates comparable to those in California? What would that mean to those who are uninsured, as well as reimbursement for doctors, hospitals, drugstores in New York?

What is even more critical to understand is that regulation although some well-intentioned can often increase costs and result in less than desireable outcomes. The huge variation in costs between health insurance and California and New York is more likely due to coverage and benefits insurers must offer in the latter state.

President Obama with his vision of improving the healthcare system, which I completely agree with, and his administration must be very careful on how it approaches that goal. For example, with the recent passage of credit card bill and increased regulation, we can expect fewer people to have access to credit. Don't believe what politicians are saying. Since two thirds of the U. S. economy is based on consumer spending and with tightening of credit due to increased regulation, we can expect that the insatiable appetite for goods and services will fall. Although the economy will ultimately turn around it will never be like it was in the past decade.

Good intentioned regulation may in fact increase healthcare costs. If the government tries to impose benefits and mandate an artificially low price, then we will find ourselves not with a privately run healthcare system but one run by the federal government. That would be a critical mistake.

Why You Should Support an Individual Mandate for Health Insurance

A recent article from the Associated Press, "Insurers offer to stop charging sick people more" is welcome news for everyone. To accomplish the goal, however, it is important to understand why the insurance industry is asking that everyone be required to purchase health insurance also known as an individual mandate.

Without an individual mandate, people who don't need medical care and view themselves as healthy won't participate. As a result, the costs for those buying health insurance is higher for two reasons. First, those who want health insurance are often those who need medical care. Since their costs are often higher than the insurance premiums they pay, these additional costs must be borne by someone else (that would be those paying for health insurance but not requiring medical services). Second, if those healthy non-participants do require medical care, like emergency room services, because they don't have insurance and usually cannot afford the costs, hospitals and doctors don't just absorb this free care, they also pass it on to those with insurance.

Understandably there will be complaints from many who don't wish to be mandated to purchase health insurance, however, for the insurance mechanism to work properly, like Medicare and Social Security, it requires participation by all to work. As a result, those individuals with pre-existing conditions who are currently offered unaffordable coverage may in the future get their own insurance plan.

Although the theory of insurance makes sense, time will tell whether insurers do what they are supposed to do, make insurance affordable when everyone pays into the system.

The complete article follows:

Insurers offer to stop charging sick people more
By RICARDO ALONSO-ZALDIVAR, Associated Press Writer Ricardo Alonso-zaldivar, Associated Press Writer Tue Mar 24, 7:08 pm ET

WASHINGTON – The health insurance industry offered Tuesday for the first time to curb its controversial practice of charging higher premiums to people with a history of medical problems. The offer from America's Health Insurance Plans and the Blue Cross and Blue Shield Association is a potentially significant shift in the debate over reforming the nation's health care system to rein in costs and cover an estimated 48 million uninsured people. It was contained in a letter to key senators.

In the letter, the two insurance industry groups said their members are willing to "phase out the practice of varying premiums based on health status in the individual market" if all Americans are required to get coverage. Although the letter left open some loopholes, it was still seen as a major development.

"The offer here is to transition away from risk rating, which is one of the things that makes life hell for real people," said health economist Len Nichols of the New America Foundation public policy center. "They have never in their history offered to give up risk rating."

"This letter demonstrates that insurance companies are open to major insurance reform, and are even willing to accept broad consumer protections," said Sen. Jeff Bingaman, D-N.M., a moderate who could help bridge differences on a health care overhaul. "It represents a major shift from where the industry was in the 1990s during the last major health care debate."

Insurers are trying to head off the creation of a government insurance plan that would compete with them, something that liberals and many Democrats are pressing for. To try to win political support, the industry has already made a number of concessions. Last year, for example, insurers offered to end the practice of denying coverage to sick people. They also said they would support a national goal of restraining cost increases.

The latest offer goes beyond that.

Insurance companies now charge very high premiums to people who are trying to purchase coverage as individuals and have a history of medical problems, such as diabetes or skin cancer. Even if such a person is offered coverage, that individual is often unable to afford the high premiums. About 7 percent of Americans buy their coverage as individuals, while more than 60 percent have job-based insurance.

"When you have everyone in the system, and you can bring (financial) assistance to working families, then you can move away from health status rating," said Karen Ignagni, president of America's Health Insurance Plans, the leading trade group.

The companies left themselves several outs, however. The letter said they would still charge different premiums based on such factors as age, place of residence, family size and benefits package.

"If the goal is to make health care affordable, this concession does not go far enough," said Richard Kirsch, campaign manager for Health Care for America Now. "It still allows insurers to charge much more if you are old." His group, backed by unions and liberals, is trying to build support for sweeping health care changes.

Importantly, insurers did not extend to small businesses their offer to stop charging the sick higher premiums. Small employers who offer coverage can see their premiums zoom up from one year to the next, even if just one worker or family member gets seriously ill.

Ignagni said the industry is working on separate proposals for that problem.

"We are in the process of talking with small-business folks across the country," she said. "We are well on the way to proposing a series of strategies that could be implemented for them."

___

On the Net:

America's Health Insurance Plans: http://www.ahip.org

Blue Cross and Blue Shield Association: http://www.bcbs.com/

Local ABC Channel 10 affiliate Part One - Open Enrollment

Was thrilled and priviledged to be on the local ABC Channel affiliate. Thanks to the host, Sharon Ito, who asked excellent and insightful questions.

Primary Care Crisis Will Doom Universal Coverage and You

While it made the news all too briefly recently, a report in JAMA found that there still continues to be a primary care crisis. Even Dr. Dean Ornish commented on the problem in a recent Newsweek piece.


This is a big problem. Fewer US medical students wish to do internal medicine or family medicine because of the administrative hassles, decreasing compensation, and increasingly demanding workloads. It isn't necessarily because they are lazier or more money hungry than previous generations because doctors currently in primary care are retiring, leaving medicine entirely, or doing something else like hospital medicine or urgent care. Students are opting for fields that offer work-life balance which include radiology and dermatology. And why not? The way the healthcare system is structured, the more procedures you do the more you are compensated which isn't always in your best interest. Doctors, who are paid to be more cognitive, like primary care, as a result can spend much more time with a patient and prevent complications from happening, but because the specialty isn't procedurally based, they have continued to watch their income decrease. With increasing medical student loans, it shouldn't surprise anyone that the crisis is at hand.

Why is this a problem for you? It is expected that with the baby boomers that the nation will need to increase the number of internists by 38 percent or roughly add 2000 internists per year. As a nation, we only train about 1000 internists that will go on to do primary care and that number is falling rapidly. With a shortage of primary care doctors, it means you are more likely to get worse care, pay more, and wait longer. Research consistently shows that patients with a primary care doctor do far better healthwise and financially than those that don't.

Adding more stress is the goal of the nation to address the 47 million uninsured. While Senator Obama and Senator McCain both have healthcare plans, neither actually address universal coverage, which may be years away because if everyone is covered, not everyone can access the healthcare system. We don't have enough doctors. Take the Massachusetts experience where health insurance in mandatory. Although the state has more primary care doctors per capita than any other state in the union, the newly insured now are either unable to find an accepting doctor or need to wait an average of seven weeks to see one. Though legislators want to increase the number of students trained, the fact is students won't go into the field until the issues that are causing those to leave are addressed.





The problem is that no one is willing to address the fundamental problems anytime soon. To do so, specialists would have to give up some of their income. After all, we spend a lot as a nation and it is unlikely we can increase the total amount spend to make up for the deficiency, but will need to re-distribute some of the income. This is why it won't happen.





Get ready to get more fragmented uncoordinated care, increased costs and frustration, and worsening health outcomes. If you still have a primary care doctor, then give him or her a hug because they are disappearing rapidly and frankly their skills and expertise are priceless.

What is Your Waist Score?

The NY Times reports that in Japan companies and local governments will need to measure waist sizes of their population. Those considered "metabo" or overweight will be educated on how to lose weight and then measured later. If they still aren't at healthy weight, the companies and governments will be charged more for healthcare costs. (Japan has a publicly financed healthcare system).

It will be interesting to see how this program will do. Will people be healthier because the entire nation is focused on not being “metabo”, the preferred Japanese word for overweight? Will companies and local governments, who are responsible for measuring waist lines and ultimately financial penalties if their population, help change the lifestyle in Japan to be more healthful? For example, if your company produces food for the nation, do you promote smaller serving sizes? If you are a local government, do you greenlight more parks and neighborhoods that promote physical activity? Measuring waistlines gives us a starting point and a proxy of the health of a nation.

What will be fascinating to see is what they do with that data. It will be more, however, than simply re-educating people. We all should know that being overweight or obese, which is the status of 2/3 adult Americans, is not healthy, but the challenge is how do we make our increasingly hectic 24/7 lifestyle more supportive for staying active and eating well?

Health Savings Accounts - A New Way of Paying for Medical Care

The Wall Street Journal reported about a report from the General Accounting Office that found those individuals who purchased health savings accounts tended to be wealthier. Health savings accounts (HSAs), which must be coupled with a health insurance plan with a high-deductible, has been the cornerstone of the Republican plan to improve healthcare inflation. Certainly the premiums for a high-deductible plan are significantly cheaper than traditional plans by up to 50 percent and the rate of health care costs slowed to about 3.6 percent as compared to 7 percent for companies that adopted HSAs. The concern among some is that those with HSAs are getting less medical care and services.

Is this a bad thing? It depends. If individuals decreasing unnecessary care because now they are responsible for the deductible then less consumption of healthcare is a good thing. If, however, people are putting off or delaying important preventive care this could be more costly and detrimental in the future. Preventive care can often find problems before they become expensive debilitating problems.

For example, would you delay getting your car maintenance if you had a high deductible? It depends. If you could not afford to have your car breakdown at the most inopportune times, then you might get routine regular preventive care. You might even do it yourself and change the oil and rotate the tires if you knew how to and had the time. If, however, you didn't know what to do, then you might not do it or figure it is unnecessary and take your chances. The difference between our bodies and our cars is you can always buy a new car.

From the article:

• Some analysts say much of those employer savings come because many HSA participants tend to forgo care. "There is a lot of evidence that suggests that when patients pay a higher percentage of the cost of their care they get less of it," says Michael Thompson, a principal at PricewaterhouseCoopers, which advises employers on health plans.
• Self-employed attorney Jonathan Stein, 34, of Elk Grove, Calif., got an HSA in 2005. Because he is responsible for paying the entire bill, he didn't go to the doctor for a recent bout of flu and doesn't get annual physicals despite a family history of heart disease and cancer. "My doctor and I fight about that when I do see her because she wants me to come in every year," Mr. Stein says. "If it was covered by insurance I'd probably go."
• Watson Wyatt expects 54% of big companies next year to offer high-deductible health plans, many of which are HSA eligible, up from 39% in 2007. Since the plans were introduced in 2004, more than six million Americans have enrolled in HSA-eligible plans, although that represents a small percentage of the more than 200 million people with private health coverage.

HSAs make sense for individuals who know when to get care and when to safely skip care. Having less medical care isn't a bad thing as long as it makes sense and won't cause problems in the future. Who best to figure that out? Empowered and educated patients. If you don't feel like you have the knowledge or expertise to figure it out, then who next? A primary care doctor. After all, if you are like many people, you don't do the actual car maintenance yourself, you have a trusted mechanic tell you what needs to be done. The same applies to your health. The difference is that your health advisor is your doctor.

Sicker? Pay More. Healthier? Pay Less.

Insurers are now asking patients to shoulder more of the costs for expensive life saving drugs than in the past as a way to manage rising healthcare expenses. Is anyone surprised? A NY Times article found that:

• insurers abandoned the traditional arrangement that has patients pay a fixed amount, like $10, $20 or $30 for a prescription, no matter what the drug’s actual cost. Instead, they are charging patients a percentage of the cost of certain high-priced drugs, usually 20 to 33 percent, which can amount to thousands of dollars a month.
• Private insurers began offering Tier 4 plans in response to employers who were looking for ways to keep costs down, said Karen Ignagni, president of America’s Health Insurance Plans, which represents most of the nation’s health insurers. When people who need Tier 4 drugs pay more for them, other subscribers in the plan pay less for their coverage.
• But the new system sticks seriously ill people with huge bills, said James Robinson, a health economist at the University of California, Berkeley. “It is very unfortunate social policy,” Dr. Robinson said. “The more the sick person pays, the less the healthy person pays.”
• Traditionally, the idea of insurance was to spread the costs of paying for the sick.

While it would be easy to blame the insurers for doing this or the employers for asking the insurers to come up with more affordable premiums, the real reason for this cost shifting is because health insurance is this country is not considered a shared responsibility among all. Specifically, the healthy buy health insurance not only for themselves but also to partially subsidize those who are ill.

Increasingly however our healthcare system is stratifying into different segments with the healthiest opting out or only paying what their true costs are. As a result, those who are sickest need to pay even more than in the past because there are no others to subsidize their costs.

Without true healthcare reform, i.e. universal coverage, these kind of stories are only going to continue. That's the real tragedy.

McCain's Healthcare Plan is the Worst - Consumer Driven Healthcare Not the Answer

FORTUNE magazine published an opinion piece in their March 17, 2008, issue titled Why McCain has the best health-care plan. McCain like many of his fellow Republicans believes that giving individuals more responsibility is a way to solve the healthcare crisis.

Frankly, expecting Americans will use tax incentives to find their own healthcare insurance is laughable. Already when tasked to fund their own retirement, the vast majority don't want the responsibility, are inadequately prepared and planning to work longer. This is despite planning for their retirement is in their best interest. Who wants to be forced to work longer if they don't have to? Companies are discovering that although they relinquished their responsibility of helping their employees' retirement by eliminating the pension plans for the cheaper 401k plans, workers are not better off. Many workers even fail to enroll in the 401k plans and many that do are only invested in the money market option, which won't keep up with inflation. Now many employers are stepping in, requiring mandatory 401k enrollment (workers can opt out), and defaulting the funds into a mutual fund that has better returns.

Experts who believe that the consumer will make the right choices when given the important job of finding their own health insurance, funding it, and making best use of it obviously aren't aware of the consumer experience with retirement planning. An entire industry has developed to help people plan for retirement. Will the same occur in healthcare? Who will be the healthcare advisors? Doctors? Insurance agents? A new field of advisors?

If the public approaches the responsibility of healthcare insurance the same way it does with personal retirement planning, our country is in big trouble. Unfortunately unlike postponing retirement, a person can't predict or delay when he will get ill. Relying on the public to shop for healthcare will result in many more being uninsured, others not getting preventive care, and a workforce that will be increasingly unhealthy and unable to compete in a global market. As an insider I know what to do in this new world, but what about the rest of us? Specifically, what about you?

Republican Healthcare Proposal Is Not Universal Coverage

The Republican candidates' proposal for healthcare reform does not provide universal coverage and is far more radical than those offered by the Democrats. Unlike Senator Clinton and Senator Obama, who would create a new government agency or system to offer the insurance plans available to members of Congress for those individuals who are unable to get coverage through their employers, the Republicans instead propose to give individuals and families tax credits to buy insurance. They want individuals to have the ability to buy insurance from other states where they currently reside. They would remove the states ability to regulate insurance companies arguing that individuals from one state should be free to purchase another plan offered at another state if it is cheaper. Currently insurers have to abide by state law, so if one state requires insurers to provide certain benefits, the cost may be significantly higher than another state which does not have those requirements. It is hoped that with the tax credits and allowing competition of insurance plans from different states that health insurance will be more affordable. Republicans believe quite strongly in consumer driven healthcare.

By changing the tax code and asking individuals now to shop more for health insurance, rather than employers, in many ways is very different than how the majority of Americans get health insurance. Currently, large employers are working directly with insurers and doctors demanding that they deliver high quality healthcare so workers simply need to choose from available plans during open enrollment. They don't need to worry about tax credits or taking the time to research what health insurance plan is best for them. Frankly, research shows that Americans don't want the responsibility of researching health insurance plans because it is so confusing.

What they propose mirrors what occurred with employers regarding retirement plans. In the past companies provided employees a pension plan. When they became too expensive to administer, most shifted from providing pensions to 401k plans, where individuals were simply given money to invest. Since everyone plans to retire, one would have thought individuals with the new responsibility would have taken an active role and invested wisely. What research has shown is in fact that they often don't enroll in 401k plans, and if they do enroll they don't actively manage their money or don't know how to invest, so that now many can't retire. Companies are now changing their policies and requiring employees to opt-out if not interested and are investing the money in a mutual fund with a retirement target date on behalf of their employees.

I expect the same behavior to occur when it comes to health insurance. It would seem that individuals would take charge of their health because they have more "skin" in the game. They might change their behaviors of smoking, overeating, alcohol use, and adopting a sedentary lifestyle and replace it with a healthier one. Perhaps, but from the retirement savings example, I doubt it. If you don't mandate people to do something they won't. The stakes are far higher than that of retirement planning. At least you can always make more money if you are healthy. If you are sick, you can't necessarily buy yourself good health. Too many of us take our health for granted. It is so precious and precarious that even the most healthy and unassuming children, who haven't had the chance to abuse their bodies can get very ill from cancers and other illnesses.

My biggest difficulty accepting the Republican plan is that I think health insurance is not a luxury or an optional purchase but a necessary requirement for individuals to stay well and if one gets ill, it prevents someone from going bankrupt as he tries to get better. This plan doesn't seem focused on providing universal coverage even though the American Cancer Society estimates that 1 in 2 men and 1 in 3 women during their lifetimes will develop cancer, the second leading cause of death. Note this statistic does not include skin cancer, which is extremely common or the leading cause of death, heart disease. This means we all can expect a medical problem sometime during our lives. What isn't clear is when.

Time will tell if this is the right plan for our country.

Health Net ordered to pay $9 million after canceling cancer patient's policy

An arbitration judge slapped for profit health insurer Health Net with a judgment of $9 million in favor of a breast cancer patient who had her policy canceled as she underwent chemotherapy. What is frightening is the case highlighted the shameful practices of for profit health insurers. This patient, who had other insurance prior to Health Net, appears to have been aggressively courted by its sales force to switch because it would save her money. It certainly didn't save her from grief as see was saddled with over $100,000 in medical expenses, stopped chemotherapy for months until she could find a charity to cover costs, and unnecessarily worrying about whether she could get the right care, even though in good faith she bought coverage to avoid all of this.

It is a worrisome trend in California, which could be a sign of things to come across this country. Insurers under pressure from employers to slow rising healthcare costs while also seeing double digit rate increases in medical expenses are trying to find ways to do both. Just skipping the ethical discussion of whether for profit insurers should be in the business of healthcare, as any household, business, and government that expects to do well should know, what you bring in (income or revenues) must be more than what you pay out (bills or expenses). It appears insurers are trying to cancel policies for patients, who don't disclose their medical conditions (known as pre-conditions) on their applications retro-actively. According to the LA Times article, Health Net, like many other insurers do so because it is "necessary to hold down costs by weeding out people who may have failed to disclose pre-existing conditions on applications for coverage. They say cancellations happen infrequently." Wellpoint, one of the nation's largest for profit insurers is in favor of changing this practice as is Health Net. Blue Shield had no comment.

Health Net argued that they would have never provided coverage had they known about her weight and her use of fen-phen, a dietary drug that was shown to increase the risk of heart valve problems and pulmonary hypertension which can be fatal. Although obesity can increase the risk of breast cancer, there was nothing to her history to indicate a personal or family history of breast cancer.

What does this mean to you? While the practices illustrated in this case clearly are very disturbing, particularly giving bonuses to staff for meeting a set goal of revoking policies, it shows that insurers are having a difficult time balancing astronomical healthcare expenses and the inability to raise premiums to cover this. As a result, they are more aggressive and critical about who to insure. Without healthcare reform, it is easy to see what will happen. Those with even the slightest problem, like being overweight or obese, will be denied coverage. Those with existing medical problems won't be able to get coverage at all. In fact, ironically the only people who will be able to get coverage are the young and healthy, the group of people that can't afford coverage or are not required to have coverage to offset those who are ill. The underlying premise of insurance, that all chip in to cover those who have an adverse outcome, does not apply in the healthcare industry.

It is clear that there will be fewer insurers as weaker ones drop out of providing health insurance. But unless insurers can balance the revenue and expense equation, the end of the story is simply this, the government will step in and need to provide either financial guarantee and backing like they do for flood insurance or complete government takeover of the insurance industry. It's easy to bash insurance companies and their egregious behavior should not be condoned or tolerated, but is it a sign of how desperate the situation is in our healthcare system which is the most dysfunctional in the world?

Majority of Americans Support Mandatory Health Insurance

With the nominations for the Republican and Democratic parties underway, healthcare has been a hot topic. In this country, 47 million Americans are uninsured. The proposed plans by the candidates vary. One of the stickier issues is whether everyone is required to have health insurance. A survey of adult Americans found that

• 80 percent of Democrats
• 52 percent of Republicans
• 68 percent of Independents

supported the idea that everyone should have insurance. For those that could not afford it that , they felt that the government should help.

This makes absolute sense. As we all get older, the need for health insurance and healthcare increases. Answering this question, whether health insurance is essential or optional is only one of many questions we must answer if the healthcare system will be reformed in a meaningful way. Hopefully we will see it in our lifetimes. Until then, make sure you are doing the right things to stay healthy.

Healthcare Reform - Dutch or Swiss?

The New York Times reported that Health and Human Services Secretary Leavitt was going to Switzerland and the Netherlands to see how these countries provide healthcare. In those countries there is an individual mandate, i.e. everyone has to buy health insurnace. Employers are not required to provide health insurance.

Unlike Canada and Great Britian, it appears these countries don't use the government set up the system. Will elements of the Swiss and Dutch healthcare systems work here? It probably will depend on who sits in the White House and who controls Congress.

Insurance Type and Appendicitis

An interesting article in the New York Times titled "Likelihood of Burst Appendix Tied to Insurance".

From the report, "But the kind of insurance — or lack of it — had a significant effect. Compared with patients who had private insurance coverage, those on Medicare were 14 percent more likely to have a burst appendix, people on Medicaid were 22 percent more likely, and those with no insurance at all were 18 percent more likely to have a rupture. The differences persisted even after controlling for age, sex, socioeconomic status, type of hospital and other factors."

The authors admit that this is a retrospective study and it is unclear the reasons why the difference was seen.

Health Insurance - Odds 1 in 3 Yours Isn't Doing Everything to Keep You Well

One hundred million insured or one in three Americans have no idea if their health insurance plan is doing everything to keep them healthy. This ignorance could cost them their lives. This is the conclusion from the recently released 2007 State of Health Care Quality report by the National Committee for Quality Assurance, a non-profit organization which for over a decade has accredited health insurance plans for their performance. NCQA rates health plans on their ability to provide their enrollees with basic and proven preventive treatments, controlling high blood pressure, diabetes, cholesterol, among many others, consistently and routinely. While the industry has made significant improvements, much more needs to be done to save lives.

When NCQA started reviewing the quality of care delivered, it found that in 1996, on average only 62% of heart attack patients were getting beta blocker medications. These medications have been proven to decrease the risk of future heart attacks and prescribing them to these patients has been the standard teaching in medical schools for years. Over the past decade on average 98% of the time heart attack patients in health plans accredited by NCQA receive this treatment.

Unfortunately, health plans that didn't submit information for review did less well with 94% of patients getting the prescribed medication. Although it most situations this would be good enough, each drop in percentage translates into lives that could have been saved with a simple proven intervention.

Because this and many other effective preventive treatments weren't done to the level recommended by expert committees, 75,000 insured Americans died prematurely. Had these individuals accessed high performing health plans they would be alive today. If the entire industry performed as well as the top plans, $3.7 billion spent on hospital costs would have been avoided. Preventive care saves lives and money when done consistently and regularly. The problem is that within the healthcare system this is far from the case.

Part of the problem is that the most popular insurance plan, the PPO plan, does not have the same level of scrutiny when it comes to performance or accountability like a HMO plan. Until last year, no PPO plans provided NCQA any information on how well they did to keep you well. This year, those plans that cover one hundred million Americans still have not committed to submitting information for review. This lack of transparency has California's insurance commissioner developing a report card rating PPOs, much like the current system which lists HMOs, available to consumers by 2009. Until then, you have a one in three chance that you are in a plan that answers to no one and that the care you receive is not ideal.

Fortunately you aren't powerless. With open enrollment, now is a good time to see if your choices whether HMO or PPO include a NCQA accredited program by going to www.ncqa.org. If not, ask your human resources department to consider one for next year. Take the same amount of time and diligence you would do researching for your next car. It's your money. Don't you deserve the best care possible? With buying a car, if you purchase a lemon, you always have another chance to get another one. With your health, the stakes are higher. Choose wisely. The information is available. Act on it. Next year tens of thousands won't be around to rectify their mistake. Make sure it isn't you.

Open Enrollment - Picking Health Insurance As If Your Life Depended On It

It's that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the "perfect" Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention.

But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimated that in 2005, 83, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely -- because the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association were not done.

The performance gap between the top 10 percent of health plans with the national average on measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, exceeded 20 percent. For the airline industry, banking, and manufacturing, the quality gap was less than 1 percent. Would you be worried about flying if you knew the safety performance between the best and average was 20 percent. When it comes to health care, consumers erroneously assume that all health plans are created equal.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . Only this recently have PPOs (preferred provider organizations) started to submit their performance on these basic, yet important preventive measures. It is possible that you still have a chance of not knowing whether you're choosing a poor-quality health plan this year.

What can you do? You aren't completely powerless. First, check out the NCQA website and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It's your money. Don't you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. With hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.