Now we just have to get ACOG on board too.  C-section rates in the US are far higher than the World Health Organization recommends, and women here who have a breech baby are routinely herded into the OR, with little choice in the matter.  Jay was born breech, and so was his sister.  Neither was a c-section, and both turned out great (you can pay me later, Jay).  Obviously those are just two incidents (and we all know that anecdotes are not data) but had Jay and his sister been born 30 years later than they were, Jay’s mother would have been subjected to two major abdominal surgeries - which also involve risk - that she didn’t really need.

In the current quest to reform health care, everyone is talking about controlling costs.  Lowering the rate of c-sections would have a significant impact on the cost of maternity care, since vaginal births are much less expensive than surgical births.  Maternity care is something that most women eventually use, and lowered costs would translate to lowered health insurance premiums for all of us.  I have friends here in Colorado who have been subjected to routine c-sections because their babies were breech, and in one case the parents ended up paying several thousand dollars out of pocket for the birth, since the surgery was done at an out-of-network hospital.  A change in protocol for breech births seems like it would benefit mothers, babies, and health insurance companies (and all of us who pay premiums for insurance).  Let’s hope that ACOG follows in SOGC’s footsteps.

I found Amy’s article in Grand Rounds last week, hosted at Florence dot com.

Based on my own very un-scientific surveys over the years (mainly talking with my own friends and acquaintances), I don’t think that most people are aware that Medicare does not cover long term care.  I think that people with lots of money (who tend to have financial advisors) know that they need long term care insurance.  At the other end of the spectrum, people who have very little money might qualify for Medicaid without much “spending down” in their later years.  But it’s the people in the middle who are probably most likely to be thrown for a loop by the costs of long term care.

Long term care insurance is a bit like disability insurance, in that both are likely to be needed at some point, and yet they aren’t high on most people’s lists of must-have insurance products.  Is it because we don’t like to picture ourselves needing long term care, or being disabled?  Is it because the products are expensive? Life insurance isn’t something that most of us particularly want to think about needing to use either, but term life insurance policies are very inexpensive.  Long term care is a more expensive product, and thus requires more of a sacrifice on the part of the policy holder.

I think that there’s a general perception that once a person becomes eligible for Medicare, medical expenses will no longer be a worry.  While Medicare does provide a good safety net for older Americans, it’s far from complete on its own.  Medicare Part D, Medigap policies, and long term care insurance are all pieces of the puzzle too, but might not be widely understood by people who haven’t yet experienced the Medicare system.

I agree with Mike that we need to be having a discussion here in the US about how to better fund long term care.  Private insurance policies work well, for the relatively few people who purchase them.  But I think more intensive public education is needed in terms of what is and isn’t covered by Medicare.

I found Mike’s article in the Cavalcade of Risk, hosted last week at Supporting Safer Healthcare.

I’ve been thinking about this for the last couple days.  First of all, health insurance companies have some work to do in the public opinion department.  So it is a bit of a mystery to my as to why the executives who met with congress were so adamant that rescission not be limited to cases of intentional fraud.

But the flip side of the issue is that it’s tough to really differentiate between intentional fraud and accidental omission.  The only person who really knows what an applicant’s intentions are is the applicant.  Do we use the “reasonable and prudent person” idea here?  Would a reasonable and prudent person forget that she had been hospitalized or taken to the ER?  Probably not.  Might she forget that she had been treated for a sinus infection six years ago?  Perhaps.

When I was new to the health insurance business, I remember hearing a story about a lady who “forgot” to mention on an application that she had emphysema.  She was later diagnosed with cancer and her policy was rescinded.  There is no part of me that believes that a person with emphysema could answer “no” to the question about lung/respiratory conditions and chalk it up to an accidental omission.  Health insurance applications are designed to eliminate accidental omission as much as possible.  There are health questions relating to pretty much every body part and organ system.  And then there’s a catch-all question at the end, asking for details about any conditions not specifically mentioned.  Any illness that required more than a passing glance from a doctor would be tough to forget when answering such specific questions.

Some people do lie intentionally when completing health insurance applications.  These people might not realize that rescission is a possibility, and might not understand what a dicey situation they’re putting themselves in.  In Colorado we have a high risk pool health insurance policy that is available for people who don’t qualify for individual health insurance.  Cover Colorado is far superior to getting an individual policy based on a fraudulent application.

Another problem is bad agents.   Over the years we’ve spoken with numerous clients who tell us that they have condition XYZ, but mention that their last agent told them that they didn’t have to list it on their application.  I have no idea what these agents are thinking.  All of us know about the possibility of rescission - it’s a basic part of health insurance license training and continuing education.  I don’t know if these agents are just trying to secure their own commissions, or if they honestly think that the condition is minor enough that it doesn’t need to be listed, or if they think that not listing it will make the process easier for their clients.  But no agent should ever tell a client to leave anything off of an application.  If a condition is minor enough to not be an issue, the underwriters will dismiss it.  But that is a decision for underwriters, not agents or applicants.  Any other course of action is way too risky.

The waters get pretty murky when it comes to looking at an application and determining what an applicant’s intentions were.  Did the person set out to deceive the insurance company?  Were they completing the application at the end of a long day, with a crying baby and a kid who needed help with homework?  Did one person complete the application for an entire family, and forget to mention a treatment that a spouse had several years ago?  Did they ask their agent for advice and get told that they could just not mention the condition on the application?

Several years ago, I spoke with a representative from Anthem Blue Cross Blue Shield about the issue of policy rescission.  She told me that - at least here in Colorado - rescission is reserved for serious cases where significant conditions are left off of applications, and that had the conditions been revealed during the application process, coverage would have been declined.  To me, this seems fair.  If a pre-existing condition is revealed after the approval process is complete, it should be underwritten just as it would have been if it had been noted on the application.  Trying to determine whether an applicant intentionally lied or genuinely forgot would just be speculation anyway.

Electronic medical records that allow underwriters to see complete medical histories at the time of application would greatly reduce the number of policy rescissions.  Then again, there’s a lot of talk on the table right now about eliminating medical underwriting all together, which would solve the problem once and for all.

Duncan Cross is very familiar with the health care system in the US.  He’s been through more than his fair share of medical procedures.  And he’s not impressed with a recent WSJ editorial that calls for Americans to take on more of the cost of their health care.  I can absolutely see his point.  He’s had to self-ration health care because of money.  He struggles to afford COBRA.  He’s already paying a good chunk of his income for health insurance and health care.  And his chronic illness means he’ll have to keep doing so indefinitely.

But I think that the WSJ editorial might have been aimed at a different sector of the population.  Although there are plenty of people like Duncan Cross who pay all of their own health insurance premiums and then have to continually pay out additional amounts for treatment of chronic illnesses, there are others who pay little or nothing for their health insurance premiums (thanks to employee benefits) and have very low copays when they seek care.  I was talking recently with a friend who is pregnant.  She had a baby a few years ago, and spent a total of $200 for the pregnancy and delivery.   She mentioned that her new health insurance plan is “nickle and diming” her, because she had already spent $200 for prenatal care and ultrasounds, and was going to end up paying another few hundred dollars by the time the delivery (a scheduled c-section) is complete.  This is the sort of person that I think the WSJ editorial is aimed at.  I honestly don’t think that she knows or cares how much her prenatal care and surgical delivery cost.  Her portion is a tiny fraction of the total, and yet to her it seems like a lot of money.  It’s all relative.  I have a friend who paid $7000 for her c-section delivery - and yes, that was with health insurance.  Both women had employer sponsored health insurance, but with drastically different coverage.

Proponents of HSA qualified, high deductible health insurance plans say that they make people think twice before utilizing health care.  The jury is still out on whether this is the case.  I know that a lot of our clients in Colorado request HSA qualified plans, mainly because the premiums tend to be lower.  Jay and I have an HSA qualified plan, and it has worked well for us.  But we’re healthy, with no chronic medical issues, and we’re the sort of people who would think twice (or six times) before utilizing health care anyway.  Even when we had fancy group health insurance coverage with $15 copays, we never went to the doctor.   I have a feeling that a lot of our clients who request HSA qualified plans look at health care the same way.  We don’t mind shouldering a potentially hefty chunk of our health care costs, because we typically don’t have much in the way of health care costs.  I have a suspicion that the people who wrote the WSJ article are probably in a similar position.  But the perspective probably looks a whole lot different if you’re not only paying for your own high deductible health insurance, but also facing the prospect of meeting that deductible year after year.

I found Duncan’s article in this week’s Grand Rounds, hosted at ACP Internist.

We spoke with an underwriter at Humana who said that we had to wait at least 12 months after having the lipoma removed, and then have a doctor write a letter stating that it was gone.  We finally got around to having that done last week.  Jay got a note from a doctor here in Broomfield that says that the lipoma is gone.  We also have a copy of the receipt from the original removal procedure.  Tomorrow we’ll submit the paperwork to Humana, and hopefully the lipoma exclusion will be deleted from our policy soon.

It’s a lot of hoops to jump through, but if you have an individual health insurance policy in a state like Colorado that allows pre-existing condition exclusion riders, you might want to double check to see if your rider can be re-evaluated.  Most carriers in Colorado require that the condition be resolved (treatment and symptom free) for at least a year before you can request a review of the rider.  Some exclusions will never be removed, like the internal fixation rider on Jay’s arm.  He has a titanium rod in his arm from a snowboarding accident years ago, and as long as the rod is in his arm, the exclusion will remain.  Since the rod is permanent, so is the exclusion.

But other exclusions can be subject to review once a condition is resolved.  The same applies to someone who quits smoking.  If you pay tobacco rates on your individual health insurance policy and then quit smoking, you can request that your rates be reduced.  Most carriers in Colorado require that you be smoke-free for 12 months before the rate can be lowered, but it can make a significant difference in the premium, and is definitely worth pursuing.

If you’re at all interested in health care reform, I highly recommend this edition of the HWR.  You’ll surely find a viewpoint you agree with, as well as plenty of counterpoints and ideas that you might not have thought of yet.  I’m a big believer in educated decision-making.  Topics like health care reform sometimes become so politically polarized that people start to think of one side as good and the other as bad, with no gray areas in between.  Forums that allow multiple, often conflicting, ideas to be shared alongside one another are a great way to get past argument and start to find common ground.  Read through the articles in the HWR and you’ll see what I mean.

I don’t know what to say that Gawande hasn’t already said.  I think that the article should be required reading for everyone in the health care industry.  Doctors, nurses, hospital administrators, health insurance executives, pharmaceutical company employees, and health insurance agents - we all need to read this article.  And really think about it.  There’s a quote in the article from a doctor who says “we took a wrong turn when doctors stopped being doctors and became businessmen.“  I would take that a step further and apply it to the entire health care industry.  We are not in a luxury products industry, or one than can be funded with discretionary income.  We all need to take a long hard look at our motivations and what we consider to be our primary responsibilities.  Anyone who puts making money at the top of the list might be better served in a different profession.  Obviously, making money will be somewhere on the list - we all need an income.  But the health care industry isn’t a place where money should be the driving factor.

I was pleased to see that Grand Junction, Colorado was mentioned in the article as an example of a city where health care costs have been reigned in by cooperation between physicians and encouragement from the main health insurance company in town (the article doesn’t name names, but my guess is that the HMO in question is Rocky Mountain HMO, which is based in Grand Junction).  Hopefully Gawande’s article in the New Yorker will encourage other cities to emulate the model that Grand Junction has created on Colorado’s western slope.

Over the last couple years, as health care reform has become an ever-pressing issue in this country, one consistent theme I’ve noticed is that most people are considerably unaware of what is actually on the table, and how the various reform proposals would impact our healthcare and our wallets.  People tend to throw around terms like “singe payer”, “universal health care”, and “socialized medicine” without really understanding the key issues.  There’s plenty of fear-mongering going on, and there are plenty of sad stories that reflect on the failures of our current health care system.

Very few people have time to sit down and read through 615 pages of legislation - even if it does have large font.  In my reading so far, I’m seeing lots of things that would be very beneficial to the clients we serve in Colorado who are purchasing individual health insurance: no underwriting, premiums that are not based on gender or health history, and no lifetime maximum on benefits.  I haven’t yet found any wording about how these changes would be financed though, and that could become a sticking point.  A lot of the changes would essentially eliminate the major differences between individual and group health insurance… and it follows that the lower premiums on individual health insurance would likely disappear too.  Everyone is anticipating government subsidies to be a major part of health care reform, but there is quite a bit of debate going on right now as to where we’re going to get the money for the subsidies.

My initial thoughts are that I wish that politicians would focus on just the most important aspects of health care reform, and write a simple, short bill, aimed at expanding health insurance coverage to the nearly 50 million Americans who are currently uninsured.  Make it simple to understand, so that the average person can read through it and form an opinion, without needing to rely on an interpretation drafted by their media outlet of choice.  I’m sure this is too much to ask, since brevity doesn’t seem to come standard on any government bills.  But I’ll throw it out there as my two cents.  Now if you’ll excuse me, I have a lot more pages to read.

This is astounding to me.  If we look at all industries, only two show profits greater than 20% for 2007 (network/communication equipment, and mining/crude oil production).  Further down the list we see “Insurance: Life, Health (stock)”, with profits at 10.6% of revenues.  Stick with me here, and click on the life/health insurance industry link, where you’ll see a list of 15 individual companies.  Nearly all of them focus on life insurance, disability insurance, long term care, annuities and other retirement planning services.  AFLAC stands out as a recognizable player in the health insurance industry, but their product is supplemental, and not designed to be stand-alone health insurance coverage (and they also focus on disability and life insurance products).  From what I could determine, three other companies on the list provide some type of health insurance coverage (but seem to be mainly focused on other insurance products): Conseco, Torchmark, and American National.  Conseco and Torchmark both sell supplemental and “a la carte” policies.  American National is still a mystery after my few minutes of researching.  Their website says that they sell major medical plans as well as accident and sickness plans.  But they don’t provide any plan details that I could find, and instead direct consumers to an 800 number to talk to a sales rep.  I don’t know for sure, but I’m going to hazard a guess that health insurance isn’t their mainstay if that’s how they’re marketing it.

The industry as a whole chalked up a profit margin of more than 10% in 2007, but that was carried by the life insurance side of the industry.  Health insurance companies don’t fare nearly as well when it comes to making profits.  Far more of their revenues are eaten up by claims, which continue to grow year after year as health care costs increase.

Interestingly enough, the al la carte insurance idea, written as a piece of satirical genius, reminded me of policies that are sold by some of the less scrupulous health insurance carriers in Colorado.  If your health insurance application is asking you to decide whether you’d like to have coverage for cancer and ambulance rides, you might want to keep shopping.  Health insurance isn’t like ordering a sandwich at Subway.  None of us know what might happen to us in the future.  I’m a big fan of keeping premiums down by choosing a high deductible, HSA qualified plan.  But if and when I meet my deductible, I want to know that I’ll be taken care of - even if I end up having a medical condition that I never imagined I’d have.