I’ve arranged the cavalcade roughly by topic, but I wanted to start off with an article from Jon Coppelman of Workers Comp Insider.  It’s the story of flight data recorders, invented by David Warren, who lost his own father in a plane crash when he was a child.  Warren never profited financially from his invention, but it’s safe to say that all of us who travel by air are better off because of his work.

Healthcare

The Healthcare Economist, Jason Shafrin, shares some interesting data about healthcare utilization in conjunction with Medicare Part D.  Not surprisingly, the availability of Part D has resulted in an increased demand for prescription drugs.  Although that increased utilization is partially offset by a decreased usage of other non-pharmaceutical medical services.  But the most intriguing aspect is that “gaining prescription drug coverage was associated with worsening health.”

Evidence based medicine has had plenty of air time recently, and is often touted as a way to reduce health care costs and improve the quality of care.  But Jaan Sidorov of the Disease Management Care Blog reminds us that succession – the idea that an observable outcome must have been caused by a specific intervention – isn’t always accurate in a system as complex as health care delivery.  There are many factors that have to be accounted for, and it’s difficult to point to any single intervention as the cause of a particular outcome.

Health Business Blog’s David Williams explains a new technology that allows hospitals to create an online patient portal that is linked to the patient’s medical information.  Once the patient signs in, the website generates ads and content based on the patient’s specific medical information, much the way Amazon makes recommendations based on your previous purchases.  As David points out, there is some room for problems here.  Not to mention the increased utilization that could result from specifically targeted pharmaceutical and medical device advertising.

Brian from Business Risk Management tells us about the actuaries who discovered the mistake in Anthem Blue Cross Blue Shield’s initial CA rate increase request, and how correcting the problem lowered the rate increases from an average of 25% to an average of 14%.

InsureBlog’s Bob Vineyard gives us his take on health insurance for children starting this fall:  scarce and expensive.  There is no way that it’s going to be a simple or cheap process for all children to gain access to guaranteed issue health insurance (especially in the absence of any mandate requiring all children to have coverage).  There has been confusion around this part of the law for months, and it’s reasonable to assume that other states will follow suit in terms of setting up new plans for children or ceasing to offer child-only coverage for the time being.

The Notwithstanding Blog addresses President Obama’s alleged hostility towards consumer directed health plans.  It’s true that consumers tend to want the latest and greatest in health care, which leads to over-utilization.  We here at the Colorado Health Insurance Insider are big fans of HSA qualified policies and consumer directed health care in general, but we recognize that it has it’s limitations.

Offshore Drilling And Risk Management

Claire from the Insurance Industry Blog discusses the potential for litigation surrounding the health of workers who are involved in the Deepwater rig disaster clean-up efforts.  If we recall the health problems that arose for rescuers and demolition crews after 9/11, it makes sense that something similar could happen this time too.  Hopefully all possible precautions will be taken to protect the thousands of people who are working to save the Gulf.

In keeping with the oil rig theme, and with a fascinating discussion of managing unthinkable risk , we have an article from Actuary Info called “the LORD and Risk Management”.  Check it out.  I know you’re curious.

Life And Long Term Care Insurance

Miranda from Budget Life reminds us that funeral costs can be a burden on loved ones when you die, and that they are one more reason to have at least some life insurance in place, or a reserve of funds to pay for the funeral.  She also gives us a look at some of the most expensive funeral options out there… want to be made into a diamond?  For 25 grand, you can do just that.

Free Money Finance explains four scenarios that increase the chances you’ll eventually need long term care (and thus long term care insurance unless you’ve got some other way of paying the often very steep bill that can go along with long term care).

Liability, Auto, And Business Risk Management

If you’re an uninsured motorist in the UK, you better get some insurance soon.  Car Insurance Blogger tells us about a new system in the UK that is linking the Motor Insurance Database with the Driver and Vehicle Licensing Agency, automatic plate recognition systems, and police national computers to track down uninsured motorists.  I wonder how feasible such a system would be here?  Probably a bit more complex, given that we have 50 states, all with their own laws concerning auto insurance, and their own licensing system.

Attorney Nina Kallen takes her daughter’s camp to task for not having liability insurance.  It sounds like the camp is covering it’s legal bases by having the parents sign a waiver releasing the camp from liability if something happens to one of the kids, but I’d say that Nina’s right in this situation… liability insurance is a good idea.

Being in the health insurance industry, we tend to think of pre-existing conditions in terms of medical issues.  But an article by Tred R. Eyerly about a flawed construction project illustrates how pre-existing conditions can cause nasty litigation between P&C carriers as well.

Nancy Germond writes about the various insurance policies that you may need if you’re starting a new business.  The example she uses is a roofing business, but a thorough discussion with an experienced insurance agent is a must when starting any kind of business.

Risk Management In Investing

Should you buy gold as a means of diversifying your assets?  The Silicon Valley Blogger explains how adding gold to your portfolio can be helpful as a risk management tool, and also provides several avenues people can use to buy gold.

Proponents of a health insurance system with little or no government regulation might believe that the government shouldn’t dictate what types of policies can be sold, but rather that the free market will figure it out.  But we know that underwritten health insurance doesn’t operate in the same type of free market model as say, designer handbags.  It’s a lot more complicated than that.  And buying the wrong coverage can cost a consumer far more than just the premiums.

Most people shopping for health insurance look for advice from their family and friends, agents and brokers (not all of whom are honest and ethical, unfortunately), and marketing materials created by health insurance carriers.  Very few people read all the fine print on their policies during the 10 day free look period.  Often they just put the policy in a drawer until they need medical treatment, at which point they might find out that the policy they got is full of holes.

If something sounds too good to be true, it probably is.  That’s good advice, and is very applicable when it comes to insurance.  ”Discount plans” that offer to cover your whole family for $99/month with only $25 copays for doctor visits are fairly easy to spot as scams (although unfortunately some people do still buy them).  But when a policy is actually labeled as “health insurance” and has lots of familiar terms like deductible, coinsurance, network, etc., it can be harder to spot the -sometimes gaping – holes in the coverage.  Often these policies are sold by lesser-known carriers, and sometimes the premium will be lower than policies sold by more reputable carriers.  But a closer look might reveal very scanty annual or incident maximums, “optional” coverage for essential services like chemotherapy, no limits on out of pocket expenses, and the list goes on.

The new regulations won’t have much of an impact on good-quality policies from reputable health insurance carriers.  Those plans already provide solid coverage for essential services.  But removing the worst policies from the market – or forcing them to improve their coverage – will protect consumers who might otherwise have bought those plans thinking that they were as good as all the other options.  And that’s a good thing.

Beth’s article was included in the Health Wonk Review this week.

Although we could see it, we couldn’t get it out.  We tried briefly, but were afraid we would push it further in or that it would somehow wiggle it’s way into his sinuses, so we decided that the wise choice would be a trip to urgent care.

After our son’s finger incident last winter, he’s understandably wary of doctors, and as soon as we got out of the car at the urgent care clinic, he started saying “no doctor, no doctor”.  Hopefully he’ll remember that next time he thinks about sticking something in his nose.

We went to an urgent care that is part of Poudre Valley Health Systems on Harmony and Timberline in Fort Collins.  The receptionist greeted us, took our insurance card and id, and started filling out paperwork for us.  She asked us if we had attempted to remove the stone ourselves, and we told her what we had tried.  Then she mentioned that if we wanted to possibly save $140, there was one more thing we could try:  Hold his other nostril shut and blow into his mouth.

So Jay did just that.  And on the third blow, the rock came shooting out of our son’s nose.  We were thrilled – no need to sit in the waiting room at the urgent care facility, no need to subject our son to whatever instruments doctors use to extract stuff from toddler noses, and no need to pay for an urgent care visit (we have an HSA qualified policy with a $5000 deductible, so we’d have been paying for the whole thing).

We were in and out of the clinic in under five minutes, and it didn’t cost us anything.

A lot has been said about over-utilization of health care lately, and the need to reduce both cost and utilization in order to make our health care system sustainable.  But I wonder how many urgent care clinic front desk people would be willing to give out free advice like that, and how many would have just taken our insurance info and sent us in to see the doctor?

So he proposes an alternative:  an open source history and physical exam that would allow different doctors to access and add to each other’s notes without having to duplicate work already done by someone else.  It makes perfect sense, and does seem like a much better way to avoid errors in patient care.

Happy notes that such a system would work best with a bundled care reimbursement model, and that some doctors are nervous about such a system because they fear that they would earn less money overall.  But he goes on to point out that earning a little less money might be well worth it if your job is easier and you get to spend far less time repeating tasks that someone else has already done.  In addition, there would be less paperwork (electronic or otherwise) for health insurance companies to process, which should result in lower administrative expenses.

I love this idea.  I’m a big fan of technological advancements in health care billing, charting, prescribing, etc.  In an era when we can carry around phones the size of a deck of cards that double as palm-top computers, medical providers should be able to spend their days helping patients rather than worrying about getting their coding just right (and duplicating the work of six other doctors in the process) in order to get paid.

There are many reasons for the dramatic increase in c-sections over the last couple decades.  Too much medical intervention, a legal system that pushes doctors towards c-sections at the first sign of a hiccup in the birth, parental requests, ACOG’s recommendation against VBACs, etc.  Some have also pointed out that doctors make a lot more money for doing a c-section, and can do one a lot faster than it takes to wait for a laboring woman to give birth on her own.

It seems like that last one should be relatively easy to fix, if reducing the c-section rate is indeed a priority.  To make the math easy, let’s say that a surgical birth costs $20,000 and a vaginal birth costs $10,000 (these are completely random numbers.  The real numbers vary dramatically from one state to another, and from one health insurance network to another).  If we say that the goal should be no more than 15% c-sections, we can say that for 100 births there should be 85 vaginal deliveries (amounting to $850,000) and 15 c-sections (amounting to $300,000).  Add those two amounts ($1,150,000) and divide by 100 to get the average price of a delivery if we were to achieve a c-section rate of 15%:  $11,500.  In reality, the math would be much more complex than I’ve made it here, but the basics would remain the same.

Now that we have the average cost of delivery if no more than 15% of deliveries were surgical, that could become the standard payment for all births, regardless of whether a c-section were performed or not.  There would be no financial incentive for doctors to opt for c-sections, as they would no longer receive higher compensation for doing so.  The tough medical malpractice environment that OBs practice in would likely provide more than enough motivation for them to continue to do c-sections when there was a true medical emergency, despite the fact that they would know there would be no additional compensation for the birth.

The rising c-section rate is driven by a variety of factors, and obviously the problem needs to be confronted on many levels.  But it seems counter-intuitive to expect doctors to reduce their c-section rates when we’re paying them more to perform them.

Obviously this wouldn’t work for all seniors.  People who are living on social security without any other income would be hard pressed to come up with $375 to be seen by a doctor who doesn’t take Medicare.  And others might balk at the idea of seeing a doctor who doesn’t take Medicare, regardless of whether they could afford the care.  But for those who are open to the idea and able to afford the services, Dr. Dappen does make it sound like a good deal.  No hassle, no waiting, and the doctors will visit your home if you can’t go to them.

I’m curious what a procedure like this would have cost if the patient had opted to see an in-network Medicare provider in an office setting?  As Dr. Dappen pointed out, an ambulance with a stretcher and paramedics might have been needed to transport her to the doctor depending on the severity of her osteoarthritis.  That alone would have been more expensive than the procedure itself.

House calls are definitely still rare these days, but they are gaining in popularity as our population ages.  The Independence At Home Act of 2009 created a test program to see if money can be saved and outcomes improved for 10,000 of the sickest Medicare patients – people with multiple medical conditions, who have needed high cost health care in the previous year.  Time will tell how it works, but the idea is promising.  Keeping people in their homes helps to make them comfortable, reduces stressful transportation issues, and also avoids possible infections that spread easily in medical offices and hospitals.  Obviously for serious situations hospitalization would still be necessary, but for dealing with more minor illnesses and injuries, and especially preventive care, home visits make a lot of sense.

Private health insurance companies tend to take some of their cues from Medicare in terms of what they cover, so if Medicare eventually makes home visits more available, it stands to reason that people with private health insurance might also have access to house calls from doctors, even if they can’t afford to pay full price to a non-network provider.

Dr. Dappen’s article was included in Grand Rounds this week, hosted by Bongi at Other Things Amanzi.

The controversy surrounding homebirths (and midwives versus obstetricians) has been in the news again lately with the release of a new study that claims that homebirth is associated with a higher neonatal mortality rate than hospital births (registration required to view the Medscape article).  This has met with some fierce criticism from people who (rightly so, in my opinion) claim that the study results are politically and financially motivated.  The debate around whether births should be attended by OBs or midwives is much like the debate around health care reform.  People are very wrapped up in their own beliefs on the subject and become pretty fired up when talking about it.  It’s hard to distinguish real science and facts from hype and fear-mongering.  It’s difficult for me to consider points made by ACOG on the subject of homebirths as valid, because of their strict stance against homebirths and their obvious financial bias.   But I will readily admit that I have a bias in favor of homebirth.  Such is the way of human nature when it comes to controversial topics…. if we have opinions on them, we tend to hold tightly to them.

The US c-section rate rose by 53% from 1996 to 2007, although in Colorado and five other states the increase was a whopping 70%.  That trend doesn’t show any sign of reversing itself anytime soon.  As Jason noted in his article, there is a “cascade of interventions” in hospital birth settings that is steadily driving up the rate of surgical births.  In addition, we have a malpractice system that provides a strong incentive for doctors to perform c-sections at the first hint of a problem.  With a system like that, it’s hard to fault OBs for taking the c-section route, and intervening in general.  We can wring our hands all we want about how we need to reduce the rate of c-sections and medical interventions during childbirth, but as long as our malpractice system penalizes doctors for avoiding c-sections, we won’t make much progress.

Our own son was born at home following 45 hours of labor.  For almost nine of those hours, I had what would have been described in a hospital as “failure to progress”.  But I had competent midwives who checked our son’s heartbeat frequently, and patiently waited for me to give birth to him.  Had I been in a hospital, there is a very good chance that I would have had a c-section.  Yet our son and I both came through the birth unscathed, and a c-section would have been needless intervention.  I know it’s easy to say that in hindsight, but the problem is that when it comes to the over-medicalization of our country, we aren’t learning from our collective hindsight.

Dr. Welch also writes about late pregnancy ultrasounds doing more harm than good by finding tiny abnormalities and causing needless worry to parents when it’s far more likely that the abnormalities are nothing to worry about.  A good friend of mine went through this exact same scenario last year.  At seven months pregnant, an ultrasound revealed a problem with her son’s intestine.  She was understandably freaked out for the next two months, and was also subjected to weekly ultrasounds.  When the baby was born, he was whisked away to NICU and monitored for 24 hours (no nursing or bonding time in that first day).  The result of all that testing:  a perfectly healthy, normal baby.

I haven’t had personal experience with the over-medicalization of end of life care, but everything I’ve read about it indicates that we are doing way too much intervening there too.

Much has been said about how we need to reign in health care costs in order for health insurance to be universally affordable.   But we also need to figure out how to just use less medical care all around.  We need to find ways to support health rather than react to illness (diet is a good place to start).  And we need to question just how much we want our lives to revolve around medical intervention, pharmaceutical concoctions, and beeping machines.  As Dr. Welch noted, some medical interventions are absolutely essential and worthwhile.  But that is not the case for all medical care, and a “less is more” approach might create a healthier population and lower health care costs.

My guess is that people are starting to feel the real world effects of the bill and seeing the legislation in a more favorable light when it benefits them directly.  Seniors who find themselves in the “donut hole” in their Medicare Part D prescription coverage started getting $250 checks last month.  Colorado was one of the first states to get the new federally funded high risk pool up and running, but similar plans are coming online in all 50 states, and will make it easier for uninsured people with pre-existing conditions to get health insurance.  The early retiree reinsurance program application became available to employers last month, and will make it easier for businesses to provide health insurance to their retiring workers who are not yet eligible for Medicare.  Young adults are being allowed to stay on their parents’ health insurance policy until they are 26.  All of these programs are part of the health care reform legislation, and they all have a direct, favorable impact on individuals and businesses.

It will be interesting to watch public opinion of health care reform over the next few years.  I imagine a lot of it will depend on what happens to premiums.  If health insurance carriers can comply with the requirements of the new law without substantial premiums increases, we’ll probably see even more favorable public opinion of the law, especially once government subsidies kick in to help people pay for health insurance.

It’s true that programs like Medi-Share are exempt from the regulations established under HR3590, because they’re technically not health insurance companies.  Of course that has it’s downsides too… they are not regulated by state insurance commissioners, and they are very clear in stating that the program is not health insurance and that payments are not guaranteed.

Although regular health insurance companies do impose various limitations and restrictions on various aspects of coverage, Medi-Share does so to a greater extent.  Pregnancies to unwed mothers are not covered unless the woman can prove that she was raped.  In the event that a member has fertility treatment that results in multiple births, the program will pay up to $25,000 for complications to the mother and/or children, including the cost of the delivery.  If you’ve ever known someone who gave birth to multiples with complications, you know that $25,000 won’t go far.  I guess this is an incentive for Medi-Share members to steer clear of fertility treatments that might result in multiples (the infertility treatment itself is also not covered, but that is true of most individual health insurance policies too).  Most individual health insurance carriers in Colorado don’t offer basic maternity coverage at all right now (although that will soon be changing), but they are all required by law to cover complications of pregnancy just like any other illness.  Since medical sharing programs aren’t actually health insurance, they don’t have to abide by the rules that mandate coverage for pregnancy complications.

Pre-existing conditions aren’t covered with Medi-Share.

The mental health parity law that was passed  in 2008 has no impact on programs like Medi-Share, and mental health issues are not eligible to be shared by other members.  Neither are any conditions that stem from acts that would be considered un-Christian, such as sex outside of marriage.   HIV/AIDS treatment is only covered if the disease was contracted via transfusion, rape that was reported to law enforcement, or by a health care worker in the line of duty.  Members are not allowed to smoke, use drugs, or abuse alcohol, and conditions resulting from any of those things are not eligible to be shared with other members.

Medi-Share also does not cover routine preventive care.  In Colorado, well-child visits, mammograms and PSA testing are required by law to be covered by health insurance carriers, but since Medi-Share is not a health insurance policy, it’s exempt from the mandates.  Personally, I believe that health insurance should be more about providing a safety net to cover huge medical bills rather than focusing on small, routine, expected expenses.   But it’s something that people should be aware of if they are considering a medical sharing program… actual out of pocket medical expenses might be quite a bit higher than the “annual household portion” simply because of the things that aren’t eligible to be shared with other members.

Out of curiosity, I got quotes on the Medi-Share website for my own family.  We have no interest in joining a medical sharing program, but I was interested in seeing what the difference in price would be.  We currently have a $5000 deductible HSA qualified policy.  For a policy with a $5000 annual household portion, we’d pay about $240/month (including the discount we’d receive for being healthy).  We currently pay $336/month for our health insurance policy.  To me, the extra money we pay to have a policy that comes with written guarantees, a contract, and oversight from the division of insurance is worth it.  Medi-Share’s website states that “Health insurance comes with a contractual guarantee to pay your medical bills. For over 17 years our participants have been faithfully sharing medical bills on a non-guaranteed basis…”  For some people, that bit about no guarantee of payment might not be a concern.  But the reason I have health insurance is to protect our family in the event of a catastrophic illness or injury.  If that were to happen, I want to know that I have a real health insurance company paying my bills, and legal recourse in the event of a dispute.  I like knowing that my health insurance policy is regulated by Colorado’s Division of Insurance, and I like the fact that it doesn’t say “this is not health insurance” anywhere on my policy information.  For that peace of mind, I’ll pay an extra $96/month for my family’s coverage, which does come with preventive care coverage.