Monday Carnivals...

Despite some tech diff's (Blogger apparently suspended his "main" blog) , Clint at Million Dollar Goal is hosting this week's Carnival of Personal Finance.

He's chosen an interesting, if unorthodox, format: instead of listing each blog and its submission, he put posts into categories, sans blog or author. The idea is that, if you find a post's topic intriguing, you'll click thru to see where it is.

Which is what I did. We get a number of entrepreneurs here at IB; this post, at Frugal for Life, is the first in a two-part series on work-at-home scams, and how to avoid them.

And this week's Carnival of the Capitalists is up at the eponymously-named Entrepreneur's blog. Scott, our host, sifted through over 50 submissions, organizing and ranking them according to topic (and his review). Our own Bob Vineyard's post on High Deductible High Jinx was "Best in Category." WooHoo!

In keeping with the self-selected theme of entrepreneurship, take a moment to read Steve Pavlina's post on the 10 Stupid Mistakes Made by the Newly Self-Employed.

Charge it!

Growing up, “be careful what you wish for” was always a popular saying around my home. And, as a vocal (and vociferous) proponent of Consumer Driven Health Care, I should have seen this coming:

"As consumer-driven health plans gain traction, banks and health plans are teaming up to develop health care credit cards that they hope will reduce the increased out-of-pocket costs for employees that go along with (them)."

It seems that the convenience of these cards may also have a downside: as consumer credit card debts continues to climb (according to the article, it’s about $2,300 for the average citizen), charging health care could contribute to a substantial increase in such debt.

Now, I must confess that the concept of a “credit” card for HSA’s, FSA’s, and the like is somewhat foreign to me: I’ve always considered these to be more in the nature of debit cards. That is, they simply replace my checkbook when I’m paying for health care. Whatever funds are in the account represents the amount I have to spend; no more, no less.

So it came as a surprise to me (must be my sheltered existence) that financial service companies would set these up as unsecured lines of credit, as opposed to merely account balance conduits. But that’s apparently what is happening:

“The card, at a 12.96% interest rate, may be used to pay for elective or quality of life procedures, such as laser eye surgery, cosmetic dental care, orthodontry [sic] and hearing aids. Prices for such services easily go into the thousands, but Citi Health Card enables patients to "structure payment plans of up to 48 months, so members can customize their payments to fit their overall financial planning and medical spending."

The first two items, at least, aren’t even “kosher” by IRS standards; that is, they’re not eligible for tax free reimbursement under Section 213d. The beauty of our capitalist system is that folks are free (for the most part) to buy the things which are important to them.

Maybe I’m just a fuddy-duddy, but I’m skeptical that a credit card is the best vehicle for CDHP’s. Still, it will be interesting to see if the idea takes off.

Worst. Pre-Ex. Ever...

"An Oregon man who went to a hospital complaining of a headache was found to have 12 nails embedded in his skull from a suicide attempt with a nail gun, doctors say."

Oooookay.

But that's not the best part.

This is:

"The unidentified 33-year-old man was suicidal and high on methamphetamine last year when he fired the nails — up to 2 inches in length — into his head one by one."

Well, of course he shot them "one by one." Those semi-automatic nail guns are expensive!

On a sad note, the Darwin Awards have thus lost an outstanding nominee.

Stupid Carrier Tricks...

So Medical Mutual of Ohio (a fairly large, state-wide carrier) just bought Summit Insurance (a much smaller one). The deal’s been in the works for at least six months, and was finalized and announced a month or so ago.

So far, so good.

The actual transfer of business is set to take effect on May 1, so the carriers scheduled a series of meetings to familiarize brokers (agents) with what the sale means, what changes we can expect, and to answer any questions we might have.

Yesterday, I attended the last of 4 locally scheduled broker meetings:

First, the representative from Summit got up and spoke for about 45 minutes (which was approximately 35 minutes longer than was necessary). One could tell that the gentleman was not pleased to see his beloved company fade into oblivion, but we got that message pretty early on. He fielded a few questions, answering some, and passing others to the MMO person.

When Mr Summit was finished, he turned the meeting over to Ms MMO. She also spoke for a bit longer than was necessary.

There were, of course, a number of important (and urgent) items, but the two “take away” pieces were:

■ Although most maintenance prescriptions will (theoretically) transfer over from Summit to MMO, controlled substances and compounded meds will not; they will have to be re-prescribed. While this may not sound like a big deal, it certainly could be: physicians are restricted in how many of these scrips they can write for a given individual. Ooops.

■ Any procedures pre-authorized by Summit, which are scheduled for May 1 and later, must be re-authorized (by MMO). Granted, this makes sense from a claims standpoint, but announcing it only 10 days in advance is, well, stupid. How many such procedures will now have to be re-scheduled, as well?

The icing on this particular cake, however, took place near the end of the meeting. Our presenters had been unable to answer about half of our questions. So, I raised my hand:

“I have a more big picture question. Y’all have been working on this for over 6 months, and yet you’ve been unable to answer a lot of the questions we’ve asked today. And, this is the fourth such meeting you’ve held. We have no idea what questions were raised, and left unanswered, in the other three meetings. So, will there be an email or fax that addresses all these questions for us?”

Ms MMO replied that “that’d be a great idea. But we haven’t been writing them down, so we don’t know what all of them were.”

Yeah, me too.

A Study in Contrasts

The auto industry's efforts to rein in employee health costs is drawing an expensive reaction, as union workers and their spouses hurry to Michigan doctors for knee replacements and other elective procedures before they lose their comprehensive medical benefits.

Contrast this to another group whose benefits are provided under a single payor system.

The family of a 57-year-old Meath Park woman says it will take at least three months before their mother gets to see a Saskatchewan oncologist who can tell her if her cancer is treatable or fatal.

One group has virtually free and unlimited access to health care.

Hip, knee and shoulder replacements at the Henry Ford Health System were "up 20 percent in the second half of last year and remain strong," said Robert Riney, chief operating officer of the system, the largest hospital group in the Detroit area.


The other has free but LIMITED access to health care.

Emily Morley has already waited a month to see an oncologist since receiving her biopsy results that identified her secondary cancer, but were inconclusive in determining the primary source. Until that primary source is identified, her treatment cannot begin.

And even though the cancer is now in Morley's lungs, liver, pancreas and spine, the Saskatoon Cancer Clinic has advised her it will still take at least three months to see an oncologist.

One group is almost pillaging the coffers for elective procedures that will improve the quality of life but not extend it.

"In the last six months, we've noticed a significant increase in people seeking elective surgical procedures in anticipation that they might be losing their health benefits," Mr. Riney said. He would not say how much his health system was billing the auto industry because of the last-minute rush to have elective procedures performed.

While the other is simply hoping to stay alive.

"As of this point, she doesn't even know if this is terminal or not," her son Chris Andersen told reporters at the legislature Wednesday.

And folks say OUR health care system is broken.

Health Wonk Review, WooHoo!

The fifth installment of HWR is up at the Envisioning blog. This bi-weekly compendium continues to grow, and this week's version is particularly well put-together. Make sure to check out each of the Einstein "photo's."

Since Consumer Driven Health Care is a something of a meme here at IB, I particularly appreciated FoIB MarketPlace, MD's announcement of a "Blogposium" on CDHC. An extremely informative and interesting piece.

Norris vs Annuities: A Reality Check

No, not that Norris: One of our clients is a law firm which deals with administrative and compliance issues for qualified plans. For example, they’re the folks that take care of our agency’s 401(k). We’ve always had a good relationship with the firm, and it recently got even better:

Turns out that one of their other clients is a reasonably large local financial services firm, from which a number of folks will be retiring over the next few months and years. They have a “defined contribution” plan, which guarantees a lump sum to each participant, and from which each participant will receive a monthly income. The vehicle of choice for such applications is a Single Premium Immediate Annuity.

SPIA’s are custom made for this. I give the computer (or the carrier) the participant’s age, sex and the lump sum amount, and I get the monthly income that each participant will receive for as long as they live. Simple enough, right?

Not so fast, Buckaroo:

Back in 1983, the Supreme Court handed down what’s come to be known as the Norris Decision. Because women (as a group) outlive men (as a group), the monthly benefit amount which a woman would receive from a given lump sum is less than the amount for the man. Makes sense: the original sum has to last longer, in general.

Norris, though, said that such discrimination violated the ban against sex discrimination in employment in Title VII of the '64 Civil Rights Act. So, an annuity which used gender-specific assumptions was a no-no. The upshot is that in cases which must be Norris-compliant, one needs to use a unisex annuity. Simple enough.

Except that there is no such animal. By definition, annuities which pay a lifetime income are based on the sex of the annuitant. But that doesn’t matter to Norris, which bans such discrimination even if the only annuities available are based on sex-segregated annuity tables.

Ooops.

So now what?

Well, it turns out that there is a plan available that seems to meet the Norris challenge. It was, in fact, designed specifically to do so. The only drawback, if there is one, is that it is a group annuity, which the employer (plan) itself owns. And it is this program which I’ll be looking to as I continue working on this case. My only real problem with this is that I like to have choices for my clients, and this seems to be the only such product on the market.

Still, beats having to say “sorry, I can’t help you.”

Babe Alert!

Jenni, hostess of ChronicBabe, has kindly linked us as one of her Fab Five favorite sites. She says InsureBlog is a "smart (that would be me) and snarky (that you, Bob?) look at all things insurance."

Thanks for the kudos, and back at ya!

Retro Underwriting

This has nothing to do with underwriters wearing Madras shirts with pocket protectors. Retrospective underwriting, or retro underwriting, is the practice utilized by some health insurance carriers to cancel coverage and rescind back to the effective date.

This usually occurs following a claim of some significance when an audit of the underwriting file is ordered. Consider this a post-mortem on an underwriting decision made as far back as 2 year ago.

The scenario could go something like this.

You complete an application for health insurance and submit it to a carrier, we will call them Indigo Cross Health Insurance Company. In the litany of questions is one of note.

Have you ever been diagnosed, treated for or consulted with a medical professional for any of the following:

Blah, blah, blah, cancer, blah, blah.

Have you ever experienced any of the following:

Unexplained fever, swollen glands, abdominal, back or pelvic pain, . . . .

Your answer to all of the questions is “no”

The policy is issued.

Three months later you go to the doctor complaining of a pain in your gut that won’t go away.

How long have these symptoms persisted?

Off and on, maybe 4 or 5 months, but they are more painful now.

Tests are performed and the diagnosis comes back. You have colon cancer.

Then you get a letter from your carrier, denying your claim and rescinding coverage back to the effective date.

You have just entered the world of retro underwriting. In addition to dealing with the diagnosis, you now have to wonder how you will pay for your care.

Like it or not, the carrier has not only denied your claim, but cancelled coverage based on what is considered to be a false application. You misrepresented the facts by failing to mention an undiagnosed pain.

This was coupled with the admission, as reflected in the doctors notes, that this pain existed prior to the date of your application.

Is this practice fair? Yes, and no. It can be argued both ways.

Is this something to consider the next time you submit an application for insurance?

Absolutely.

Department of Counterintuition…

And yes, I (think) I just made up a new word. But it seems to fit; according to a new study in the New England Journal of Medicine:

“When coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs.”

The study purports to show that excising limits on services for mental health and substance abuse does not drive up health insurance costs, and eliminating caps (e.g. on the number of therapy sessions or days in a psych ward) does not boost spending. The "gotcha," though, is interesting: in this study, parity went hand-in-hand with managed care, which has had something of a cool reception from the behavioral health community.

The study compared several federal (government) plans that offered mental health and substance-abuse services equal to general medical benefits to plans that did not offer such cover. Of the seven, only one showed a considerable increase in usage of services, while another showed a marked decrease in usage; the rest showed little change. “Plan costs decreased in three plans and did not change in the other four. Out-of-pocket spending on mental health services decreased in five of the seven plans, according to the research.”

While I’m skeptical that adding more covered benefits doesn’t increase utilization, and costs, this study does make a certain sense: after all, the insurance industry has been touting the case for managed care for a long time, so it seems consistent that mental health cover could benefit from a little, as well.

Puts my mind at ease.

'Tis Time for Grand Rounds

And a fine job Fat Doctor does, at that. Over 50 entries, all arranged into "broad categories," including BODY PARTS AND BROKEN HEARTS. Oy!

I was most intrigued by Dr Bob's post explaining the medical coding process, and highlighting some of its history.

The (expensive) Little Blue Pill

For many years, armchair pundits have claimed that men’s fascination with the automobile is symbolic. Well, it turns out that this wasn’t so far off the mark:

"The world's largest automaker, which lost $10.6 billion last year, is shelling out $17 million annually for impotence drugs such as Viagra and Cialis...GM, which provides health care for 1.1 million employees, retirees and dependents, is the world's largest private purchaser of Viagra."

In fairness, this was a concession hard-won by the workers’ union, which dictated that such lifestyle drugs be covered by their members’ insurance:

"Once you have these benefits, it's very difficult to take them away," said Jim Sanfilippo, president of AMC Inc., an industry consultancy in Detroit."

And, of course, an aging workforce also contributes to the demand:

“(G)iven the huge number of older GM workers who might need help to "keep the spark alive," the tab for Viagra and other erectile dysfunction drugs isn't likely to go down soon.”

This challenge mirrors current health care insurance issues in general: how to keep costs in line while maintaining needed (or just desired) coverage. Whether we’re talking about Viagra, IVF, or birth control, lifestyle medications do impact the overall cost of health insurance, and seem like a reasonable place to start when we talk about medically unnecessary treatments.

Proton Pump Inhibitors

“Scottie, I need more power to the Proton Pump Inhibitors”! Proton Pump Inhibitors (PPI) may sound like something from a Star Trek movie, but it isn’t.

Instead, a PPI is a medicine to treat heartburn.

Aetna (NYSE: ΑET) is launching a six-month pilot program in the New Jersey area that waives copays for fully insured members changing to generic from brand name proton pump inhibitors (PPI) to treat heartburn or similar symptoms.

Commercial plan members currently filling prescriptions for certain brand name PPIs are eligible for the copay waiver, if they switch therapy to the generic omeprazole 20mg (the generic for Prilosec®).

Pricing 30 tabs at a major chain indicates 20mg Prilosec will run about $160.

Compare that to $15 for generic at Pharmacymex.

It is unclear from the news item if Omeprazole is available in the U.S. or if the plan will allow across the border imports. Many health insurance plans do not cover mail order meds from outside the U.S.

So how much can Aetna save if this change is successful?

Aetna estimates that more than 19,000 of its members in the New Jersey area are now receiving PPI medications, at an annual cost of $3 million

That is a significant number that cannot be ignored.

Here is another interesting tidbit to throw out at cocktail parties.

According to the Generic Pharmaceutical Association, half the prescriptions being filled in the U.S. are for generics, but annual expenditures for those medications only represent between 10 and 15 percent of the cost for prescriptions in the U.S.

Beam me up Scottie.

Money Monday: Carnivals

This week's edition of the Carnival of Personal Finance is already up at Five Cent Nickel. With 34 entries(!), you're sure to find something interesting, or at least though-provoking. I know I did: this entry from Matt Inglot explains that money is really just a tool, and why that's important to understand.

Not far behind, the Free Money Finance hosts this week's Carnival of the Capitalists. This edition boasts 43 entries, all arranged in helpful, useful categories. For a bit of whimsy, check out this post explaining the economics of Harry Potter's world.

Color Me Skeptical...

“According to a new survey released today by AARP, nearly eight-in-ten, (78 percent) of those enrolled in a Medicare prescription drug plan say they are satisfied.”

In the world according to AARP, about half the folks on Medicare lacked coverage for prescription meds; Part D has apparently helped reduce those numbers. The upside is that the new plan has helped those who’ve opted in to save some significant dollars on prescriptions.

On the other hand, "(m)illions of senior citizens have not signed up for and do not know much about" it. Almost 30 million of our seasoned citizens have signed up for Part D, but between 8 and 14 million are playing “wait and see.” Which is, of course, their right to do, even as the clock winds down on the May 15 deadline.

Not surprisingly, “(t)he drug benefit is being accepted more warmly by those who stand to take personal advantage of it than by the public at large. Half of the seniors polled approve of the plan, compared with 41 percent who disapprove.” That seems to me to be just common sense: of course those who directly benefit from a given program are going to be more favorably disposed towards it than those who are actually paying the freight.

One line in the Yahoo article jumped out at me:

“AARP is working to make the Medicare drug program even stronger by allowing HHS to negotiate drug prices for the program.”

Now, perhaps I’m reading this wrong, but I was not aware that AARP had such an unprecedented influence on the Executive Branch; I sure hope W had the courtesy of sending them a Thank You note.

Even more interesting is that, according to FoIB Kate Steadman, AARP “once supported the pharmaceutical companies' inalienable rights to demand their highest prices, AARP is now calling for the government to negotiate.”

Even stranger, she reveals that, just a few years ago, the organization “went so far as to sponsor their own Medicare Part D Plan.” And that their own studies showed that “prices in the new prescription drug benefit were lower than buying drugs from Canada.”

So which is it?

NY NY

Start spreading the news
I'm leaving today

Frank Sinatra “owned” that song. As the song progresses you find someone who wants to be in New York, the city that never sleeps.

But the Fair Share Health Care Act could drive people away from New York if fully implemented.

The act is like the Maryland proclamation on steroids.

New York’s so-called “Fair Share for Health Care Act” imposes a pay-or-play health insurance mandate on firms with 100 or more employees. These firms employ more than 70 percent of New York’s workforce, and would be subject to a tax as high as $3 per hour for covered workers. As a consequence, a firm employing a full-time, full-year worker could be subject to an additional annual labor cost of as much as $6,000.

Ouch!

Beats the heck out of the neighboring Massachusetts penalty of $295 per year.

A firm could react to the mandate by adjusting hiring practices, relocating out of New York, raising output prices, reducing the quality of their product, accepting lower profitability, or going out of business. Previous economic work suggests wage shifting is a likely response. When such an offset is not possible (due to New York’s minimum wage of $6.75 per hour), the mandate is likely to destroy jobs.

It get’s worse . . .

For those close to the minimum wage, wage shifting is not possible and employment losses ensue. The estimates suggest that between 37,000 and 65,000 low-wage workers will lose their jobs

Don’t you just love it when politicians mess with a system and make it worse?

Pay Before Pumping

As gas prices continue to rise many of the self serve gas stations (are there any full service stations left?) have instituted a policy of paying before you pump. Makes sense. If you pull into a station with your SUV running on fumes you could easily pump $50 or more into the tank before it tops off. To avoid drive-offs, scofflaws who feel they are entitled to take a 5 finger discount on gas, you now have to pay before the pump is activated.

Seems many docs are doing the same.

Collecting balances due has always been a problem for physicians

So why not do what a growing number of businesses, including every hotel, motel, and country inn on the planet, already do: Ask each patient for a credit card, take an imprint, and bill balances to it as they accrue.

Makes sense to me.

TV Causes . . .

Watching TV could be hazardous to your health, and wallet.

Until a few years ago I never knew women had vaginal itch and men had erectile dysfunction. I always assumed my toenails were just supposed to have a yellow tint and certainly did not know there could be yellow demons living under the nail that caused the discoloration.

Only recently did I learn that high cholesterol is not caused by eating double cheeseburgers for lunch but that I could blame my Aunt Jenny or Uncle Ed for this “illness”. Neither did I know that chest congestion was caused by a critter living in my lungs, complete with a couch & all the comforts of home.

In this fast paced society it seems no one has time to actually correct an illness or affliction. Instead, just pop a pill.

At one time shows like Mary Hartman & Soap were considered risqué.

Now it’s the advertisements that are discussing things that were once only talked about at a ladies bridge party.

Commercials can inform and can even entertain. Who would have known headaches were caused by a hammer against an anvil inside your head if it weren’t for the Anacin commercials years ago?

But commercials can also lead one to believe a common occurrence is something that requires a $200 drug in order to provide relief.

Sure I get edgy sometimes, but it really isn’t my fault. I know what causes the problem.

I learned that years ago.

From TV.

Everything can be blamed on mom.

“Mother please! I’d rather do it myself”!

Dale Carnegie: Spinning...

This will probably be a fairly long rant, so please be patient with me.

The title of this post refers to the great motivational author and speaker, Dale Carnegie, and his classic tome "How to Win Friends and Influence People." In it, he teaches folks effective means of communication, both in business and personal relationships.

The experience I'm about to relate might be titled "How to Effectively Damage Your Business, and Squander Years of Good Will."

Although ours is an independent agency, my P&C colleagues place the bulk of their business with a specific carrier. This is neither good nor bad, it just is. For a number of reasons, I have given this carrier's life insurance subsidiary "first dibs" on the life business that I write.

Each spring, this carrier puts on a sort of traveling roadshow, called the Annual Sales Meeting. Folks from the home office travel all over the midwest, and it gives both the agents and the home office staff the opportunity to mingle, and to share experiences and ideas. It's a lot of fun, and I look forward to them.

This year's would have been my 22nd consecutive meeting.

You'll notice I said "would have been." That's because the meeting was scheduled for the first night of Passover. This is a significant and special Holy Day, and is marked on most calendars. Now, I don't think that anyone intentionally set out to offend those of us in the field who are Jewish; most likely, it just never occurred to whomever set the dates to even check.

I was, at first, annoyed at this oversight; the more I thought about, the more irritated I became. Knowing my own limitations, I knew that I needed to tell someone how I felt, so I called the home office, and asked for the office of the CEO (hey, it's not like I have any problem calling the head honcho). I didn't really expect to speak with him personally; I just wanted to make sure that he knew that I was disappointed to miss the meeting, and offended at the reason that this was so.

My colleagues were split as to whether they thought I'd get an apologetic return call or not. I predicted that I wouldn't hear anything about it.

I was wrong.

This morning, I received a call from the Regional Sales Manager for the carrier, chastising me for not "going through channels." No acknowledgement of the offense, just a "slap on the wrist" about following their protocol.

Regular readers (and those who know me personally) will be pleased, if not shocked, to learn that I did not, in fact, lose my temper. I politely, but firmly, told the gentleman that, first, I did not want to say or do anything to damage the relationship between our agency and his company. But, I explained, I did not care about his protocol, because I do not work for him or his company. He was momentarily taken aback, but pressed on, admitting that he didn't see what I was so offended about in the first place.

At that point, I told him that, contrary to his intent, he was not helping his own cause. Indeed, he was offending me even more. I explained that I was anticipating an apology (at best), and that I would have also accepted no response at all. I concluded by asking him if there was anything else I could do for him, and we concluded our conversation.

In addition to representing this carrier, I have been a customer for over 20 years, as well: my home, auto, umbrella and much of my life insurance has been with them. As soon as we hung up, I buzzed one of my colleagues and asked her to get me the numbers for moving all of my P&C cover to our other primary company. I have also determined that I no longer feel comfortable placing business with this carrier: I am currently working on 6 life cases, all of which I will now place with other carriers.

What's so disappointing about this is that the gentleman has irreconcilably destroyed over 20 years of good-will and customer satisfaction. I sure hope he's happy.

ADDENDUM: In reviewing the phone conversation, I recalled another telling piece of information. At the very beginning of the call, the gentleman mentioned that he had received an email directing him to call me. Since I had spoken only with the CEO's office, I can only conclude that this gentleman's opinions represent those of the company itself; that is, the CEO had obviously directed him to inform me of my faux pas, and to abstain from any apology. That also speaks volumes.

A Pleasant Passover...

For those of us about to enter "The Flat Side," I wish everyone a healthy and happy Pesach!

And to my Christian friends (of whom there are many), an early Joyous Easter!

Interesting (at least to me) lagniappe: This year, our family's First Night Seder includes the Pastor of a local congregation: GracePoint Church. Don and Cindy have become good friends of ours over the years. It is truly a joy and an honor to share our home and our seder with their family.

The Oldest Profession...

Just got an interesting update. At least one health insurer has developed, and a medical plan for “guest workers,” as one of the current crop of immigration bills calls them.

I’m not really sure what the market will be; after all, these folks are getting “free” health care now, so why would they see a need for insurance?

Still, it’s reassuring to see that our industry hasn’t lost its flair for innovation. And, frankly, I don’t see a downside to this idea: if “guest workers” buy into the American dream to the extent that they want to buy health insurance, that’s “a good thing.”

The Farmer in the Dell

Earlier this week, Dell (the computer folks) announced that they’ll be offering their employees a new benefit:

“electronic health records that track their insurance claims and drug prescriptions, which the computer giant says is a key step toward letting its 26,000 staffers coordinate their own care in a bid to improve medical safety and contain costs.”

The idea is that employees’ claims info will be fed directly into the database (dontcha just love the jargon?), enabling those employees better and quicker access to their health information.

Dell’s goal is to enhance preventive care, which the company sees as a key to controlling its health care costs. It seems to be a “smart” system, as well:

“as new information is added to a worker's personal health record, the system will send out automated alerts about the kind of care that patient should get next.”

I’d be curious to see how this impacts long term health care trends at Dell. The premise seems to be that by encouraging its employees to be more proactive and informed, the company can keep rate increases down. Of course, that will depend in large part on what percentage of their workforce chooses to participate. Interesting idea, worth watching.

Told Ya So!

Last August, we talked about some of the ramifications of Anthem and Premier’s year-long “trial separation.” At the time, we learned that Anthem was reimbursing its insureds directly (rather than sending payment to the providers). And, to no one’s great surprise, a number of these “lucky ducks” chose not to pass on those claims reimbursement dollars to said providers. The results were, of course, predictable:

“Now Premier wants its money, taking legal action on what Shaw called "the most egregious cases." He said most of the suits are for bills in the neighborhood of $5,000, but they range from $1,000 to a $99,000 reimbursement check, which the patient said her estranged husband left town with.” (ibid)

So what, you ask?

Well, here’s what:

“A group of local patients have (sic) filed a lawsuit seeking class action against their insurer, Anthem Blue Cross Blue Shield, claiming it failed to cover large portions of their hospital bills.” [ed: link not yet available]

Now, you may think that this has to do with the Out-Of-Network penalties which Anthem imposed during the kerfluffle.

But you would be wrong.

The real reason for the discrepancy? Well, let’s let one of the plaintiffs do the talking:

“ Williams received a bill for $108,848.88 and later a second bill for $102,649.34. Blue Cross Blue Shield of Michigan [ed: his carrier] sent him a check without an explanation that matched the first amount, and he deposited that check into his personal account …He received a second check for $8,009.76 and deposited that check…” (emphasis added)

Further compounding the problem, he subsequently ignored all the bills he received from the hospital, leading that august institution to file suit against him. Only then did he deem it appropriate to fork over the $100,000. Of course, this only covered half his balance, which is still due, and still in litigation.

Mr Williams, et al, would do well to recall the First Rule of Holes.

This Week's Grand Rounds

can be found over at Treatment On Line. Our hosts have grouped the posts by category, which makes it easy to find just what you're looking for.

While you'rte there, check out Kevin, MD's interesting take on defensive medicine.

High Deductible High Jinks

As health insurance costs skyrocket and more people turn to high-deductible policies, a key question is emerging: When you're paying out of your own pocket, what rate do you pay?

Is it a discount negotiated by insurers, or the provider's gross charges, which could be several times higher than the negotiated rate?

Such is the tale of an uninformed policyholder, and an equally uninformed reporter.

Case in point: Lisa Stamm of Kendall, who had a simple earache and got slapped with a $375 bill for about 10 minutes with a nurse practitioner. If she had no insurance, she could have paid $125. If she had a no-deductible policy, her insurer might have paid about $140, and she would have paid nothing.

But Stamm showed the receptionist at ER Urgent Care Center on SW 137th Ave. her Cigna insurance card, and that sparked the problems.

ER Urgent Care insists she cough up the full $375. ''We as consumers have to make our choices,'' said Trudy Herdocia, the firm's vice president of operations. ``And live by them.''

With a high deductible health plan, the consumer should NEVER pay a provider on the spot for services rendered. The exception is for prescription meds.

''The theory is patients will be able to negotiate with providers,'' says Gail Shearer of Consumer's Union in Washington. ``But the theory doesn't always translate into practice. She was concerned because her ear hurt. Negotiating a rate was not at the top of her list.''

WHOSE theory? I never tell my HDHP (high deductible health plan) clients to negotiate with providers. It defeats the purpose of having the plan and is counterproductive.

But wait, there is more to the story.

It turns out that ER Urgent Care Centers are not in the Cigna network, and the firm had paid nothing on her bill because she had not met her out-of-network deductible.

This was a non-emergency visit to a non-network provider. The result is the highest charge allowed and the least credit towards satisfying the deductible.

Stamm checked with Cigna and received an explanation of benefits, one of those ''THIS IS NOT A BILL'' statements most Americans ignore. The EOB stated: ``Billed Amount $375; Allowed Amount $375; Deductible/Co-pay $375.''

Most plans have dual deductibles. One deductible is for in-network charges; the other, a much higher deductible, is for out of network charges. If Mrs. Stamm were to ask for a year end total my guess would be somewhere around 60% of her $375 would be credited toward her in-network deductible.

But the problem is worse.


The code on Stamm's bill is 99245. According to the billing codes developed by the American Medical Association, this number is for a consultation requested by another physician or source.
It involves taking ''a comprehensive history, a comprehensive examination and medical decision making of high complexity,'' according to the AMA's Current Procedural Terminology coding manual. ``Physicians typically spend 80 minutes face-to-face with the patient.''

The procedure at the doc-in-a-box was upcoded, a practice that allows a provider (who gets away with it) to demand a higher than normal reimbursement. One thing I recommend to clients, especially on bills that are significant, is that they engage the services of an independent auditor for reviewing the claim. Depending on the complexity of the bill, a fee of $100 - $300 to an independent auditor can save thousands in out of pocket expenses.

Dr Wonka, I Presume?

We’ve discussed the health benefits of my favorite bean before. But a British physician has gone one better:

“Roger Corder, a professor of experimental therapeutics, is so convinced of the possible benefits of dark chocolate that he has asked for permission to test the theory as part of the treatment for 40 cardiovascular patients.”

According to the experts, the anti-oxidants in chocolate have the ability to dampen LDL (bad cholesterol) levels.

The downside – if there is one – is that the chocolate “doses” are relatively small (about 3 tenths of an ounce, or one M&M). The article also notes that “it is probably wrong to say that all dark chocolate is good for you.” And, they’re still trying to determine which brand works best.

Unfortunately for your intrepid correspondent, the study is being conducted across the pond. Still, I eagerly await the results.

Money Carnivals

My Money Blog got an early jump on this week's installment of the Carnival of Personal Finance. Over 50 posts were submitted, and MMB did a terrific job getting them organized.

My favorite was this post on ending (or at least reducing) clutter, by the folks over at Money and Investing blog.

The Carnival of the Capitalists is also up and running, courtesy of Dane's Business Opportunities blog.

With Passover fast approaching, I really appreciated this post at Multiple Mentality, toting up the cost of our annual excursion to the flat side.

Last Minute Tax OOPS?

Joe Kristan has some helpful answers for last minute (and after!) corrections.

Thanks, Joe!

Health Wonk Review

The early April edition of HWR is up at the Health Business Blog. As usual, it's chock full of interesting posts from the more policy-oriented sector of the medblogosphere.

Marcus Newberry, who often comments here at IB, has an interesting item recommending a simple, but potentially profound, change in paying for health care: rendering full payment for professional service and then submitting the bill for reimbursement. An idea so crazy, it just might work!

Retiree Medical Costs

Pensions go bust makes headlines. But no one is talking about ballooning retiree medical costs.

States may find that what it costs them to provide medical care for retired state employees will dwarf how much they pay for their retirement benefits,

Many big companies are slashing both health and pension benefits, especially in struggling industries such as airlines and autos. But it is much more difficult for states to make similar cuts, at least for unionized employees, because that can require changing current laws.

New Jersey expects to pay more than $1 billion to provide health care for both its current and retired employees.

"And the kicker is that $721 million of that is for retired teachers," he said. Local school districts pick up the tab for teachers who are still working. "But we as a state pay the full boat for retirement benefit costs," Vincz said.

New Ideas . . .

"New ideas pass through three periods: 1) It can't be done. 2) It probably can be done, but it's not worth doing. 3) I knew it was a good idea all along!" -- Arthur C. Clarke, English writer of science fiction, b.1917

Where's Henry?

Regular readers may wonder, where is Henry?

And why is this blog listing so far to the right?

Henry is taking a few days off, and has turned control over to me.

Perhaps he will regret this, but until then . . . I have the power!!

Massachusetts Magic

Magic really doesn’t exist. You really cannot make the Statue of Liberty disappear or saw a woman in half without repercussions. But the Massachusetts legislators seem determined to go forward any way.

Everyone in Massachusetts must have health insurance under a law passed today, which the governor is expected to sign.

Those who fail to comply with the law can face penalties.

The legislation calls for uninsured residents by July 1, 2007, to purchase new, low-cost health insurance plans or forfeit their personal state tax exemption -- worth about $150 -- in the first year.

Fail to purchase insurance, it costs you $150 per year. Yeah, I can see folks quaking in their boots over that one.

The legislation also would require employers with 11 or more workers to provide health care coverage or pay an annual fee of $295 per employee

Provide health insurance or pay $295 per year. That’s a tough decision too.

Right . . . .

Individuals who do not buy plans in the second year would have to pay a fine equal to half of the monthly premium of an affordable plan, which could amount to $1,200 annually

The operative word here is “affordable”.

What kind of benefits can be found in an “affordable” plan? In a related article these affordable plans were described as “low-cost policies with scaled-back benefits.”

Does that mean a high deductible plan with little or no first dollar benefits for office visits? Or is it more along the lines of a supplemental, mini-med plan?

Observation.

The penalties are not severe enough to significantly increase participation. The premium levied for such coverage is not sufficient to provide more than just very basic coverage that could well be funded by a savings account. The flip side of the coin is that one can (probably) find cat cover for $200 per month if the deductible is at least $5,000 and possibly higher. I really have no way to gauge the cost of health care in Massachusetts.

I could be wrong, but I think someone is trying to make an elephant disappear.

Must be magic . . .

UPDATE: FoIB Elisa has more on this over at Healthy Concerns. And so does Kate, over at Healthy Policy. Wow.

A Killer on the Loose?

Is there a killer on the loose? Are the very meds that have helped so many now a threat?

Marcus Faulk of Louisville, Ala. also had a bad reaction to Advair or to Serevent, one of the two drugs it comprises. He started out on Serevent and "said that every time he took the medicine it made him feel worse," says his aunt, Annette Glanton. A few weeks after Faulk tried Advair, he collapsed on the floor of a relative's home, late on the night of Jan. 6, 2003. Just 20 years old, he was dead by the time the ambulance pulled up to the hospital, his Serevent inhaler still clutched in one hand.

Far be it for me to suggest a connection between a popular asthma medication and death . . . that is for the attorney’s to work out. But this article does raise questions about the safety, and more importantly, begs the question, is the medication over-prescribed?

Advair is the fourth-best-selling drug in the world, with $5.6 billion in sales, up 19% in 2005, and 21.1 million U.S. prescriptions. Many patients swear by it. It also is one of the most heavily advertised drugs:

And this is something else to consider.

the drug has moved far beyond a narrow audience of severe asthma patients to reach those with mild cases and nonasthmatics who simply have a bad bronchial cough

So how serious is this?

Now growing evidence suggests that a small percentage of patients--perhaps 4,000 people a year, by one doctor's estimate--may be dying because of Advair or its Serevent component.

Certainly 4,000 people sounds like a lot, but how does this look statistically?

The six-month study, when extrapolated, suggested one extra death for every 700 patients on Serevent for one year.

That would seem significant to me.

"A large number of patients are being treated uselessly," says Fernando Martinez, professor of pediatrics at the University of Arizona. "We have to target these medicines to those that need them. What's happening now is many patients get the combination straight away."

Are doctors over-prescribing or is this really a dangerous medication? The courts will decide.

Addicted to Health Insurance

Your lights are on, but you're not home
Your mind is not your own
Your heart sweats, your body shakes
Another hit is what it takes
You can't sleep, you can't eat
There's no doubt, you're in deep
Your throat is tight, you can't breathe
Another hit is all you need

You might as well face it you’re addicted to health insurance
You might as well face it you’re addicted to health insurance

With apologies to the late Robert Palmer, that is not the way the song is supposed to be but it seemed to be a nice fit none the less.

We, as a nation, seem to be addicted to health insurance. If our employer doesn’t provide it, we go without. Even if our employer pays for it, if they don’t pay substantially all of the premium we opt out.

Employers have created an environment where, if it is not covered by insurance, the individual feels no obligation to pay for the medical service. I was reminded of this while reading an article in Parade magazine this last weekend.

The article begins . . .

Vaccination over the years has reduced the incidence of and deaths from measles, mumps, rubella, diphtheria, tetanus, polio, smallpox, hepatitis B and many other diseases by more than 95%.

As one who is old enough to remember polio shots and the “new” oral vaccine it seems we have become a nation of people who have forgotten our past. Children in the last 20 years or so have been through a series of immunizations not only for polio, but DPT and MMR.

There were no vaccines for measles, mumps & rubella when I was small. I remember having all three (not at the same time) and it was no fun.

Now we have new illnesses to consider. Something called rotavirus is lurking and waiting to strike.

Worldwide, rotavirus is responsible for 500,000 deaths annually. In the U.S., 55,000 children are hospitalized with this infection every year, and 60 die from it.

Those are scary numbers, but fortunately there is hope.

There is a new oral vaccine (live but weakened) that appears to be safe, although some doctors remain wary of it. The Centers for Disease Control and Prevention (CDC) advises that all children receive three doses of this vaccine—the first at 2 months of age, the second at 4 months and the last at 6 months.

So what is the downside?

Unfortunately, it’s expected to cost nearly $200 and may not be covered by all insurance plans.

Let me see if I have this straight.

Some 500,000 people die each year from rotavirus. In the U.S. alone there are 55,000 children hospitalized and 60 will die from the disease.

But the good news is a $200 vaccine can potentially prevent your child from getting the disease.

The bad news is, health insurance may not pay for it.

Health insurance may not pay for a $200 vaccine that can keep my child healthy and maybe even save their life.

The article seems to imply this. If your health insurance doesn’t cover the vaccination some people may decide to skip it. That is lunacy.

You might as well face it, we’re addicted to health insurance.

Universal Health Coverage

Are we getting one step closer to the much debated universal health coverage plan? If you look at what is happening in Taxachussetts you might believe we are about to achieve nirvana (the altered state, not the band). Perhaps there is a rift in the universe, especially since this concept is being promoted by Republican governor Mitt Romney.

Let’s parse this out and see what happens.

Currently, people without health insurance often go to hospitals and receive care they never pay for, because the hospital and the state pick up the tab. Under Romney's proposal, uninsured Massachusetts residents would be asked to enroll in a plan when they seek care.

ASKED to enroll. Sounds simple enough but where is the stick?

If they refuse, the state could recoup the medical costs in several ways, Romney said yesterday: The state might cancel the personal tax exemption on their state income taxes, which is worth about $175

Well that certainly has me quaking in my boots. Buy health insurance or pay a penalty of $175 per year.

So what kind of coverage does one get for such a low price?

Romney said he wants to make healthcare coverage less expensive by permitting private insurers to offer low-cost policies with scaled-back benefits.

Low cost policies with scaled back benefits. Of course this ignores the fact that such policies already exist and are offered direct to the public and via payroll deduction in the worksite.

The plans have nominal benefits but do little or nothing to cover things like medicine, major medical expenses and maternity. Medicine can easily run $2,000 per month and more when fighting serious illness. A major illness or accident can reach $50,000 in a matter of days. Maternity costs can be easily managed but this ignores the fact that in many states upwards of HALF of all maternity care is currently funded by taxpayers through the Medicaid system.

Massachusetts spends more than $1 billion a year on medical care for the uninsured through its ''uncompensated care pool," and Romney argued that simply redirecting that money would pay for his plan. He said those dollars will go further if everybody has insurance, because they will see their doctors for preventive care instead of visiting emergency rooms in a crisis.

A “low cost” plan that does not cover Rx, major claims and maternity will do little or nothing to reduce the roll of the taxpayer in covering uninsured claims.

We will continue to watch as this develops but at this point I can only conclude . . . it must be an election year . . .

$24k Meds

At $17,000 a month, Erbitux is one of the most expensive cancer drugs ever made. For the record, it is not the most expensive. That distinction is currently held by Zevalin, a $24,000-a-month treatment for a relatively rare type of lymphoma.

Have you checked your policy limits lately?

A Truly Grand Rounds

For a real treat, stop by Urostream for this week's Grand Rounds. The host, a urologist, has constructed a comprehensive GR using a uniquely apt metaphor: a doctor's apppointment, complete with history and exam. Very cool (although the profusion of pink is a little much).

I was quite taken with this entry, from The Blog That Ate Manhattan (burp!), an interesting and thought-provoking post on alternative medicine.

The Elephant in the Room

There is an elephant in the room and no one wants to acknowledge it.

The cry for universal health care is getting stronger. In California (no surprise there) SB840 is (apparently) picking up steam.

What is SB840?

Universal Healthcare Insurance under Senate Bill (SB840), shouldered by State Senator Sheila Kuehl, is meant to be a single payer system that has no preexisting exemptions, no deductibles and no copay. That means that everyone, no matter their medical condition, no matter their financial standing, will be covered.

The author asks the question, who would oppose such a bill? Then he answers it

Virtually no one, except for those affiliated with the health insurance industry who stand to lose out if they are no longer the middleman between the public and proper healthcare.

How silly of me. Blame the middle man. It is the carriers fault for high prices.

So play along with me. At least the author does recognize the major fault to such a plan.

Now, the hard part; itemizing how the program will be funded.

Damn it. There’s that elephant.

An Astute Observation

My general opinion of politicians is not favorable when it comes to legislation affecting insurance matters. Most of them seem to follow the winds of surveys and give little thought, if any, to the consequences of their laws.

The AHP (association health plan), AKA the SBHP (small business health plan) has been talked about for some time as the answer to high health insurance premiums. This blog has addressed the issues of the AHP/SBHP before by pointing out how it is no different from the MEWA’s (multiple employer welfare plans) that created so many problems some 20 years ago.

But a lone voice apparently has listened to someone and has expressed an opinion that is non-supportive of the AHP/SBHP. An Ohio Democrat has hit the nail on the head and raised issues that should cause some concern, especially among those who champion the cause of the “little people”.

A Republican-backed U.S. Senate bill that's supposed to help small businesses buy affordable health insurance also would disregard current state insurance laws, says U.S. Rep. Sherrod Brown of Lorain, D-13th.

That means health providers could discontinue coverage for maternity care, many cancer screenings, kidney dialysis, basic children's health care, mental health treatment and diabetic supplies, Brown said.

I have my own issues with the AHP/SBHP, but if this will keep it from becoming law then this person has my blessing.

OT: Pet Peeve, Finance Dept

So I’m driving back to the office, and along comes one of those ubiquitous re-fi commercials. Normally, I just tune these out, but this one got to me. In the middle of the pitch comes this little gem:

“And credit card companies want even more of your money.”

No, they don’t.

They may want more of their money (back), but that is an altogether different animal. If you have a credit card, and you owe money, it’s because you’ve used their money to buy your dishwasher, or groceries, or mp3 player.

Nothing wrong with that, of course, but don’t believe for a minute that it’s your money.

It’s theirs, on temporary loan to you.

Okay, rant off.

Carnival Monday!

The Carnival of the Capitalists is up over at Jotzel (is that a cool blog name, or what?). An interesting twist this week is the ability to vote for your favorite post (hint: Bob's item on health insurance and dating).

For something a bit unusual, try Joe Kristan's post about the Iowa Interior Design Board (a.k.a. "your tax dollars at work").

Okdork blog has finally posted this week's episode of the Carnival of Personal Finance. It includes an interesting post, from Search Light Crusade, about the games that lenders play, as well as a helpful spreadsheet to help make sense of all the different rates and points.

I must add, though, that I am singularly unimpressed with Okdork's hosting efforts. Although it includes but 40 articles, they highlighted only eight, and then threw the rest into a kind of jumbled up mishmash.

By contrast, the folks at Jotzel had well over 50 posts (25% more content), yet they organized and commented on each one. And they had their carnival up many hours before Okdork (which, by the way, couldn't even be bothered to get the name of the carnival right).

Apply Yourself!

The least glamorous part of this business (what, you thought insurance was all glitz?) is completing the application. Back in the day, I always thought that the considerate thing for me to do was to ask the questions, and record the answers. That way, I reasoned, I wouldn’t wear out my clients’ hand, or my welcome.

Times change, though, and I long ago dropped that practice. There are a lot of sound reasons for having the insured complete “the app,” not least among them is the potential liability I risk in how I ask the questions and, more importantly, how I record the answers. So, I hand the app to the client, and wait patiently for him to complete it.

I do offer one admonition, however: don’t lie, and don’t volunteer. That is, if the application asks if you’ve had a bloody nose in the past 5 years, and you had one 4 years and 11 months ago, then the answer is yes. But if it truly was 5 years and 1 month ago, then one is not obligated to mention that.

The goal, however, is to be truthful, because lies (whether by commission or omission) will come back to bite you.

Which brings us to the point of this post (and yes, there really is one):

“Ten Californians filed separate lawsuits on Tuesday against WellPoint Inc, saying the insurer violated a state law banning "post-claim underwriting" by canceling policies after claims were made.

The lawsuits, filed in Los Angeles, Riverside, San Bernardino and Orange counties, accuse WellPoint of trying to avoid paying claims by retroactively reviewing policyholders' applications for discrepancies, then rescinding the policies.”

Now, WellPoint is really Blue Cross, but this issue is really about the industry, and about the application and claims processes:

“Attorney William Shernoff said in a statement that he filed the cases to trigger reforms of what he described as a widespread practice in the health insurance industry.” [ibid]

The phenomenon of underwriting at claims time is, at best, problematic. Blue Cross isn’t the only company to engage in this practice, of course, but because it is such a marketplace behemoth, it’s bound to attract more attention.

Obviously, some people lie on their applications. The challenge is that there’s no evidence that most people do. The challenge, of course, is how a carrier can protect itself while at the same time treating its policyholders fairly. And that’s not as easy as it sounds:

"At the time she completed the (application) she was 46 years of age and had never experienced any illness for Hepatitis B," the lawsuit said. "Plaintiff did not realize her childhood exposure to Hepatitis B was relevant to the questions posed in the (questionnaire)."

It doesn’t really matter, legally, whether or not Hep B has anything to do with breast cancer (as far as I know, it doesn’t). If the application asked if this patient/insured has ever had hepatitis, then that is a material misrepresentation. On the other hand, if it asked about recent symptoms, or limited the relevant question to, for example, the previous 5 years, then it is not.

The answers one gives on an insurance application form the basis of the relationship. These answers, based on the phrase “to the best of your knowledge,” are representations, not guarantees. That’s an important distinction, because it means that we have a responsibility to be truthful, but what we don’t know may hurt us.

The carrier relies on these representations in offering and pricing the product. Carriers shouldn’t routinely deny (or even just slow) claims without some reasonable basis for doing so. But they need to have some way of dealing with questionable claims, as well.

We’ll watch this one closely.

Free Health Care

Free health care. Come and get it.

Hospitals in the region gave away an average $5.11 million in medical care during the first six months of fiscal year 2005, up from $4.61 million per hospital in the same period a year ago, according to the Hospital Council of Western Pennsylvania.

With the cost of uninsured care rising, hospitals have less money for things like equipment, staff, and other expenses that affect quality of care for all patients.

The truth is, no one in this country is denied health care when they need it. Until adults act responsibly to prepare for a medical emergency the hospitals and doctors who service their needs will continue lose money on the uninsured.

A Kaiser Commission study released May 10, 2004 found that the nation's uninsured may receive $41 billion in hospital uncompensated care services this year.

Some hospitals are facing lawsuits alleging that hospitals accept discounted payments from health insurance companies while pursuing higher payments, billed at full charges, from uninsured patients. Hospitals say that individual patients, even if uninsured, rarely pay full charges and that numerous programs exist to work out discounted rates and payment plans for the uninsured.

Hospitals and the doctors who work in the ER are the only professions EXPECTED to work for free. A trend that is overlooked in the health care industry are the number of docs who contract their services to the ER. These medical professionals are not on staff and bill the patient separately for services rendered. Due to the increasing number of uninsured in the ER, many times the life saving work performed is never compensated.

To make things even more difficult, med mal insurance rates continue to climb. Trauma docs have some of the highest med mal rates in the industry.

The uninsured problem is not limited to low-income workers. In the Chicago metropolitan area 21% of families with incomes between $50,000 and $75,000 have one or more uninsured member, as do 14.6% of those with incomes above $75,000. In some cases, these higher income individuals choose not to buy coverage even though they can afford it.

Chicago-area hospitals wrote off $1.8 billion in charges for uncompensated care in 2003 – a figure that has risen steadily for decades.

Chicago-area hospitals typically collect 10% to 15% of charges for care to uninsured patients.

A business cannot survive on a 15% collection rate. Hospitals are primarily in the business of serving the medical needs of the community but when they only collect 15 cents on every dollar you have to wonder how much longer they will be able to support such losses.

People in the Greater Houston area who need immediate emergency care are dying because Houston's trauma hospitals don't have the beds or staff to treat them within the first hour after injury-the "Golden Hour"-when the best chance exists to save their lives.

The study found that the hospitals have suffered huge financial losses due to an increasing number of uninsured patients. Houston-area hospitals have provided approximately $32 million in care to uninsured trauma patients in 2001 and have sustained losses of more than $17 million from that care. "In addition to trauma beds there is a statewide shortage of pediatric intensive care beds," said Clifton. "Hospital administrators throughout the State report that children requiring intensive care beds are being flown out of virtually every urban area in the State in search of beds. The problem is related to Texas' 800,000 uninsured Texas children, almost all of whom are eligible for the federal/state CHIP program."

Uncompensated care impacts more than just the bottom line of the hospitals and doctors who serve the needs of the community. Those who have the ability to pay for or otherwise obtain health insurance but fail to do so may be impacting the quality of care for the rest of us. Somehow, 85% of the population is able to finance their health insurance coverage. Most of the uninsured, the other 15% of the population have options, they simply fail to take action and cover their risk.

Beware the Fine (and not so fine) Print

Sometimes, seemingly insignificant policy provisions can bite you. Case in point:

Recently, two of my individual HSA clients, each insured with a different carrier, came up for renewal. I suggested that we find new policies, and lower premiums. We looked around, and determined that the (relatively new) Aetna HDHP would fit the bill nicely, and so we submitted applications.

Pretty routine so far.

And then, my co-blogger Bob (in an unrelated email and subsequent post) pointed out that these plans have an internal limit of $5,000 a year for out-patient prescription drugs.

“So what?” you may ask, “I’m not on any meds that even come close to that!”

I would reply that we buy insurance for what might happen, not (just) what did happen.

Which is pretty much what I told both of these clients when I called them yesterday for permission to withdraw their applications. Both have family plans, and relatively healthy families to go on those plans. But new cases of MS (for example) are diagnosed every day. Cancer, too. Other chronic (and expensively medicated) illnesses, as well. A person with MS would blow through that $5,000 is a couple of months, and then what?

To my surprise (and delight), neither client was upset with me for suggesting that we go back to square one; in fact, they were both pleased that I’d alerted them to this potential problem.

So what’s my point?

Well, for one thing, would the anonymous voice at the other end of an 800 number (or web-site) be concerned about this? Or call (or email) back to suggest a different solution?

For another, it’s a reminder to me that what we do for our clients is important, and that I do (and should) learn knew things every day.

Mental Help

Richard G. Frank, a health economist with a specialty in mental health issues who is a professor at Harvard, said: "Clearly, the earnings of mental health professionals — medical doctors, psychologists, social workers and counselors — have either been flat or been declining for the past five to eight years."

"It's not so much the number of visits allowed by managed care to mental health professionals has changed," he said. "It's that fees paid to the mental health professionals have not been rising."

Ms. Hinterman, too, observed that patients found prescription medicines a quicker fix than "prolonged and thorough introspection."

"We just live in a culture that values speed and efficiency and wants to see complex problems resolved in half an hour," she said. Given those changes, she no longer wants to rely on the profession she trained for as her sole source of income.

No chit-chat, just gimme a pill. Drive through therapy is the name of the game.

So how is Ms. Hinterman dealing with reduced fee schedules?

An experienced seamstress, in January 2004 she started Fiber Embellishments, a company that makes scarves, table linens, chefs' aprons and one-of-a-kind bags made of boiled wool; local retailers are already selling her goods.

Wonder what Dr. Bob Hartley would do in a situation like this? Probably stand up comedy . . .

No Money, No Problem

Hospital bills for the several hundred thousand Long Islanders who have no health insurance just got cheaper.

Under provisions in the new state budget, legislators agreed Tuesday to cap how much hospitals can charge low-income uninsured patients.

Guess who is going to get screwed on this deal?

"What is most shocking is that if you're poor and don't have health insurance you could be charged two, three, five times as much as someone with Medicaid."

What is STILL overlooked is this. How much is CHARGED is irrelevant. The elephant in the room that everyone ignores is how much is actually COLLECTED from this group.

The provisions also keep hospitals from forcing the sale of a person's home to pay for medical bills and from calling in a collection agency if the person has filed for financial aid.

Attagirl

With health insurance and a little planning, getting high is as easy as getting a prescription.

And in the case of drugs that treat attention-deficit/hyperactivity disorder - which stems from low levels of brain chemicals dopamine and norepinephrine - New Yorkers are working the system.

Ritalin is a form of legalized “speed”.

"Addagurl" is the gay community's slang for the ADHD drug Adderall. Jared, 29 (who, like all subjects in this story, used a pseudonym), spends his weekends "gurling." The fashion designer got a prescription two years ago after looking up symptoms online and telling his doctor that he had them.

Now that’s something you don’t hear every day.

"ADD is such a subjective diagnosis," he says. "If you say that you have it, how's somebody going to prove that you don't? There's really no quantifiable test, so just actually knowing what to say is all you need."

When Jared, who lives in Manhattan, is planning to stay out late dancing, "three Addagurls and I'm ready to go. If you take, like, more than 30 [milligrams], it starts to feel like a combination between cocaine and Ecstasy.

"You can dose up or down according to what effect you want. You know what the comedown is going to be," he says, casually. "It is a nice benefit that it is pretty cheap and your insurance pays for it. It's safe, it's easy and it's predictable."

Not necessarily so.

Emily, 22, got a prescription for Ritalin during her last year of college. She giggles as she recounts exaggerating her symptoms during 15-minute meetings with a "bottom-of-the-barrel" doctor her school provided. (The drugs can only be prescribed by seeing a doctor in person.)

The doctor become suspicious when she admitted that she wasn't taking Ritalin every day, Emily says. But he didn't press her on it.

Instead, he renewed her prescription, eventually increasing the dosage to 20 milligrams from the original 5.

"I wasn't telling him I was taking it to stay up at night, because I know that's not really the best thing to say," Emily says. "I was just saying, 'I only take it when I really need it because I don't want to be dependent on it.' Every doctor wants to hear that."

Attagirl!

Pill Nazi

One of the funniest characters in the Seinfeld sitcom was the Soup Nazi. Anyone who has seen the show can visualize his cold stare while uttering the words “No soup for you!”.

Now we have the Pill Nazi.

The patient had high cholesterol and, according to medical guidelines, should have been taking a drug to lower it.

But her doctor didn't write a prescription. The drug was unlikely to help someone who was 100 years old and had advanced cancer. It wasn't worth the cost, side effects and hassle of taking yet another pill.

Seems the economics of medical care is invading geriatrics. What else lies ahead?

Researchers offer several case examples.

One case involves a 75-year-old woman with high blood pressure, high cholesterol, arthritis and diabetes. With a remaining life expectancy of 17 years, it makes sense to keep taking drugs to treat those conditions, researchers wrote.

But in the case of a 72-year-old man with congestive heart failure, emphysema and a six-month life expectancy, the doctor should stop prescribing drugs intended to provide long-term benefits.

Paging Dr. Kervorkian.

Elderly Americans who live independently typically take three or four prescription drugs a day. Nursing home residents typically take seven or eight prescriptions.
Studies have found that patients who take at least five prescriptions have a 90 percent chance of suffering side effects or complications from drug interactions. About one out of five elderly patients takes a drug that has a high risk and low benefit, Holmes said.

I do agree that we, as a general population are entirely too dependent on meds. But where does it stop?

Patients are bombarded with drug ads, and have been told for years about the importance of taking their medicine. So doctors might be reluctant to discontinue their prescriptions.
Nevertheless, 65 percent of all office visits end with the doctor writing a prescription. "It makes us feel good to hand something to a patient," Holmes said.

Is it any wonder why Rx claims represent almost 20% of premiums?

Insure U

Every once in a while I come across a site that is truly informational and unbiased. This is one of them.

The National Association of Insurance Commissioners (NAIC) today launched a comprehensive public education program to assist consumers with information about insurance issues. Under the banner of Insure U, the campaign has two objectives: to help consumers get smart about insurance as their needs change at different life stages, and to educate them about how to avoid being scammed by fake insurance companies. The program includes an online education site and public service announcements in English and Spanish.

The Insure U curriculum includes a basic introduction to the four major types of insurance – auto, home, life and health – as well as special considerations for young singles, young families, established families and empty nesters/seniors. Consumers can test their knowledge about insurance by taking an online quiz. Upon successful completion, they can download an Insure U diploma.

I encourage you to take some time, tour the site then collect your diploma.