Slipping Through the Cracks

[Welcome Industry Radar readers!]

Some say our health care system is broken. Others say there are problems, but for the most part, it works as well as, if not better than, other systems.

Some say universal care such as exists in other countries is the answer, yet none of them have found a perfect system either. As long as there is a limited supply of resources (medical providers, funds, etc.) stacked against an unlimited demand for services, there will be shortfalls, even in the best systems.

The WSJ recently profiled one such case. The case of Barbara Calder illustrates a combination of factors that collided to create a perfect storm of health care misunderstanding with few answers. Sadly, the health care system as it exists now is akin to the legal system where life moves at a snail's pace absent clearly defined rules that could lead to a resolution.

Front #1, "Mrs. Calder suffers from Ehlers-Danlos Syndrome, a rare genetic disorder". Barbara has a disease that affects 1 in 5,000. Very few doctors have heard of the illness or know how to diagnose and treat it. This can create a problem in any system, regardless of the way coverage is funded.

Storm front #2, even the taxpayer funded systems failed her. "Unaware of the true cause of her symptoms, she applied for Social Security disability benefits in February 2006. Her application was rejected because her disability was deemed not severe enough." Without a diagnosis, Social Security rules called for a denial. Her initial appeal was denied because she still lacked a diagnosis because a "vocational expert for the Social Security Administration argued her joint problems shouldn't preclude her from working because cooking was a "sedentary" profession".

I suppose this "vocational expert" has never spent any time in the kitchen. I cook most of the meals in our family, am not afflicted with a debilitating disease, and can tell you there is nothing sedentary about cooking.

Even when S.S. finally did approve her claim (almost 2 years after she became disabled) she has a two year wait before she can apply for Medicare . . . the government run, taxpayer funded system.

Storm #3 is the managed care system, or as we like to refer to it at InsureBlog, "mangled care". Barbara could not get a consult with a specialist without a referral from a PCP (primary care physician). She could not get special testing (to prove or disprove her illness) without approval from her carrier. Even when diagnosed, she could not get the medicine prescribed by her doctor until she followed protocol by first trying OTC medications.

All of this has been further complicated by periods where she was between coverage. When she became insured again it was under a new carrier with new rules and new providers. Each time she changed plans she had to virtually start over and learn the new rules set by each carrier.

This is a two edged sword.

If Barbara were covered under a so-called universal system (such as Medicare) she would still fall between the cracks. In fact the safety net for disabled persons is a morass of forms, waiting periods and legal shenanigans that result in all but the most diligent from becoming covered. Had Barbara not had a working spouse who was able to obtain coverage through the private funded system she would have dangled by a thread for 4 years before finding any coverage.

Coverage under the privately funded system, while flawed, at least provided some coverage and eventually led to a resolution.

Barbara's story is not over. She will most likely continue to fight private carriers while waiting on Medicare to kick in. Even then her battle will most likely continue. The government funded systems (most notably Medicare) is equally flawed but in different areas.

Her first challenge will be finding a P.C.P. who is willing to accept new Medicare patients. She may have the same issue in finding a specialist who concurs with the diagnosis and is permitted under C.M.S. rules to authorize the necessary treatment.

The combination of a rare disease, taxpayer funded programs and mangled care created a perfect storm of health care collapse. Her case is truly a sad situation and we wish her the best.

At the same time her battle is not over and may not be for a long time. Even if she were to seek "medical asylum" in another country there is no guarantee her treatment will improve. Every system with limited resources vs. unlimited demand has flaws.

No matter where she turns she will most likely find herself slipping through the cracks of an over-burdened health care system that suffers from limited funding.

Stupid Agent Tricks

[Welcome Industry Radar readers!]

We've blogged before about Agents Behaving Badly©, but here's a new twit, er, twist:

"Mississippi Insurance agent Ken Nowlin is objecting to a pre-sentence report that suggests he may have to pay restitution to Lafayette County in a kickback scheme involving the county's health care coverage."

Mr Knowlin apparently pled guilty this past summer to conspiracy charges. They arose as a result of a "kick-back scheme" relating to coverage he was assigned to secure for a Magnolia State county. In a rather novel turn of events, Mr Knowlin claims that since he did, in fact, secure said coverage, there were no damages, so nothing to be repaid.

Un-hunh.

I'm not holding my breath awaiting his exoneration.

Health Wonk Review!

First time hostess Maggie Maher hosts this week's assortment of posts on health care policy, funding and tech. Instead of the usual "list of posts" format, though, she weaves disparate posts into an interesting and compelling narrative. Ingenious, and unique.

Kudos, Maggie!

The folks at Workers Comp Insider never fail to impress me with their ability to take a potentially uber-wonky subject and make it accessible to the rest of us. This week's HWR features such a piece, written by WCI's Jon Coppelman, about an otherwise model employee fired for tardiness. But there's a twist.

Sex Insurance

Does your insurance pay for sex? If not, should it?

According to Dr. Ruth "sex is the glue that holds a relationship together".

Glue huh?

sex is considered a frill, something that is enjoyable to engage in, but certainly not necessary.

Frill? I consider it a fringe benefit.

There are lots of reasons that couples don't go to see a sex therapist when they run into problems--including embarrassment--but one of the biggest is the lack of insurance coverage.

Really?

"Gee honey, we really should see a sex therapist but my policy doesn't cover that."

That's pretty lame.


because of the lack of insurance, many such couples just fumble through these changes, often losing their sex life along the way. That’s one reason why so many older men go off in search of a mistress,

Insurance didn't cover sex therapy so I went looking for a mistress.

Right . . .

Some for Thee, None for Me (The MVNHS©)

So you're an Englishman suffering from debilitating arthritis. You've just been told by the Much Vaunted NHS© that you can't have "a drug that is widely available in Scotland" that's deemed to be quite effective.

Across the Pond, they've taken to calling this "public services apartheid." Ouch.

In addition to the arthritis meds, there's a whole raft of cancer treatments available to Scotsmen but offlimits to the English. These include lung cancer treatment tablets, implants to fight brain tumors, and osteoporosis treatments.

The problem is exacerbated by the fact that Scotland receives some 11 billion pounds (almost $23 billion) in "financial aid" from London, which serves to stoke the flames of resentment.

So, is the MVNHS© coming apart at the seams?

Time will tell.

Co-Dependency

According to the Congressional Budget Office American's are becoming increasingly co-dependent and less self reliant. It seems that, over the last 30 years at least, we have completely lost touch with reality.

We have been conditioned to think in terms of copays rather than actual costs of health care and we are paying dearly for that dependence.

We are willing to shift the responsibility for paying health care providers to the carrier.

Another important factor that both reflects and has contributed to rising health costs is the declining proportion of those costs that are paid out of pocket. Out-of-pocket payments accounted for 33 percent of all personal health care expenditures in 1975, but by 2005, that share had fallen to 15 percent

Thirty years ago individuals paid 33% of their health care needs out of pocket.

Today it is 15% and continuing to drop.

This co-dependence has got to stop. Relying on the carriers to "pay for" primary care is not going to solve anything and will only continue to make things worse.

rising health care costs (as a share of income) have probably led individuals to seek more extensive insurance in order to keep the variability of their out-of-pocket expenses from increasing.

In other words, when someone else pays demand for services increases.

Wonder where I have heard that before?

Type II Help

DiabetesNewDay.com is a great resource for helping you or someone you love live well with type 2 diabetes. The condition may be a part of your life, but it doesn’t have to be the biggest part.

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The best solution for living a full, productive, healthy life with type 2 diabetes is combining the power of information with practical resources, such as the ones on this site. Be sure to check back often!

Big Sticks, Mouths

We don't generally engage in partisan politics here at IB, but this one is just too juicy to pass up (and besides, we've blogged on this very subject before):

"SCRIPT: John Edwards: "When I'm president I'm going to say to members of Congress and members of my administration, including my Cabinet: I'm glad that you have health care coverage and your family has health care coverage. But if you don't pass universal health care by July of 2009 — in six months — I'm going to use my power as president to take your health care away from you. There's no excuse for politicians in Washington having health care when you don't have health care. I'm John Edwards and I approve this message."

That'd be some trick.

If he could actually pull it off:

"Offhand, I don’t have a clue as to where he would get the power to do that,” said Christopher Schroeder, a law professor and expert on constitutional separation of powers at the Duke University School of Law."

Seems that this little-known piece of paper (aka The Constitution) has a troublesome little clause in it about "separation of powers."

In other words, an empty threat (if not an empty suit).

Moron or Fraud: You Make the Call

[Updated - see bottom of post]

Okay, let's set the stage:

When completing an application for life insurance, one is required to answer all of the questions "to the best of one's knowledge."

One of the questions on ALL life insurance app's is: do you currently have any other applications pending (or words to that effect)?

So about a month or so ago, I get a call from Ben, who's looking to purchase some life insurance. He'd tried to do so this past summer, but was turned down by Company H due to "recent open heart surgery." Which would have made sense, except that (Ben claims) that he never had any such surgery, recent or otherwise.

In fact, he'd been in contact with Company H attempting to "set the record straight," but had had no success. I explained that this was not surprising: he needed to be working with the MIB, not the carrier. He and the Missus apparently appreciated my advice, and we went about completing his application with Company C. I also contacted our paramed service to schedule his exam (which was required due to his age and the requested face amount).

About 10 days ago, I received a note from the underwriter asking about a "plethora of activity" in Ben's MIB file. I reiterated the story of the non-surgery, and put the file aside, awaiting a decision.

Today, my Company C field rep called with an interesting development: it seems that they have received a second application for Ben, from another agent, for the exact same face amount and policy type.

Ooops.

Since my app had hit the home office first, I had dibs on the case, but they really wanted to know what was going on. I called Ben and got his voice mail; after leaving a message, I also called Mrs Ben and got hers, as well. This afternoon, Ben called back, said he was just trying to get a policy, and said he'd work with the other agent.

Not so fast, fella.

So I called my field rep back, and told him that I was not too happy about the whole situation: I had already spent considerable time, and helped resolve a problem that I hadn't even created (Company H's decline), and I wasn't too happy about just stepping aside. I also pointed out that Company C now had a major problem:

One of those two app's is fraudulent.

Hunh?

Well, let's go back to our initial stage-setting: depending on with whom he had first met, Ben lied to either me or the other agent. That is, he told us both that he had no other application pending. Since he couldn't have been at both places at the same time, one of those statements was a lie.

Now, I could agree to withdraw the app which I submitted, or the other agent could. But that would not obviate the fact that Ben had willingly and knowingly submitted a fraudulent application. And both to the very same carrier.

Had he submitted app's to two different carriers, it still would have constituted fraud (assuming the same facts), but it would be very unlikely to have been caught.

So, is Ben a fraudster, or a moron?

I have my own opinion, of course, but I'd really love to hear our readers'.

UPDATE (11/15/07): My field rep called late yesterday afternoon with more information. Turns out that my application did indeed hit the home office first, and was dated the 23rd. The other agent's app arrived a few days later, dated the 26th. While this serves to confirm my place as 1rst in line (a rather dubious distinction in this case), it also underscores something else: while it's certainly reasonable that one might forget a few stitches received 15 years ago, how does one forget completing another insurance application (not exactly the world's shortest form) three days before?

And there's this:

There has apparently been a lot of MIB activity on Ben in recent weeks, not all explained by the alleged error regarding the heart surgery. If I had to guess (and it is just a swag), I'd say ol' Ben's got more apps out there than just the two we currently know about.

My next step is the DOI, to explore the process of "dropping a dime."

Sickening Developments

Last spring, we reported on Paid Time Off Banks, where employees could treat their sick days as commodities. Of course, this was predicated on the assumption that employers voluntarily allot a certain number of those days.

But what happens when the gummint mandates that employers provide paid time off for illness?

Well first, as we've seen in every other area of the benefits equation, people will lose benefits (days).

Hunh?

Well, if the gummint mandates that employers must provide, for example, 8 such days a year, what employer would voluntarily offer any more than that?

And, of course, jobs will be lost.

What?!

Well, one proposal would require "five to seven sick days annually for full-time workers at firms that employ 25 or more people." So what do you think's going to happen to employees #25, 26 and 27? At least they'll have COBRA benefits.

And, of course, many companies will either close, or scale back significantly:

"For every $1 spent on wages, he already pays another 43 cents for vacation, health care and other benefits."

How much more will the sick time cost?

But hey, it's free, right?

Grand Rounds is up!

Dr Anonymous hosts this week's edition of the venerable medblog roundup. I think the new "Top 10 and Then the Rest" model is becoming the "new normal" (although the Doc actually has a Top 5). "The rest" includes some 38 posts, so there's bound to be something to pique your interest.

We are major advocates of transparency in health care, so I especially liked this post at Running a Hospital. It's actually the personal blog of the "CEO of a large Boston hospital," which is pretty cool in itself. The CEO, Paul Levy, posts on his hospitals venture in publicy disclosing outcome rates for infections (and yes, it's a bit dated, but still relevant).

Not to Brag, But...

We may have to work on lowering that, though: all the really cool bloggers are in Junior High.

Guess Who is Coming to Abu Dhabi?

And Turkey, China, Thailand and . . .

Just like we have exported fast food to foreign nations, now it seems that health care is moving in and taking root. Famous names like Johns Hopkins, Cleveland Clinic, Mayo, Duke and others are now "franchising" on foreign soil.

In a way it makes sense.

Just last month the original Maytag plant in Newton, Iowa closed its' doors. The dependable Maytag appliances will still be around but will be built in Mexico instead of Iowa.

If washing machines can be built in Mexico at a lower cost then why not hip replacements in India?

If Mexican workers can put the Maytag emblem on washers & dryers then why not Indian health care workers put the Harvard Medical International seal of approval on an artificial hip?

"It's not good enough any more to be the greatest name in American medicine," he says. "If one is truly going to be a global leader, [you] have to try to figure out how to work globally."

Well there you go.

Thanks to Stephanie Ramage of Sunday Paper for this tip!

Over There, Over There

It's not so much that "the Yanks are coming" as it is, what do they do with their group health insurance while they're "over there?"

That's a question I hadn't really considered until recently, when a client of mine called seeking an answer. Seems one of his employees has been called up, and is headed to Iraq for the next year.

Of course, we wish him God Speed and a safe return.

But my client wanted to know how to handle the group coverage for his employee. And that's where I came in.

Thanks to a buddy, I'm clued in to the USERRA (Uniformed Services Employment and Reemployment Rights Act), which states:

■ If you leave your job to perform military service, you have the right to elect to continue your group insurance

and

■ Even if you take a pass, you can get back on when you get back "over here"

Intrigued? You can download the details, in pdf form, here.

Transparency on Parade

Last week, at the invitation of the practice manager, I attended the gala Grand Re-Opening of a local medical practice. It was a very nice affair, complete with sushi & fresh veggies, yum!

But not nearly as nice as the the pricing list prominently posted by the receptionist's window.

Yes, a pricing list, including all the services available. Right out in the open. In plain English (not "medspeak").

WooHoo!

Yes, it's been a long time coming, and we still have a way to go (after all, this currently represents cutting edge, not ubiquitous). But what a great start!

IB Kudos to Pain Alternatives!

Affordable Health Insurance Test

This is only a test. If it were real life, most people would make a failing grade.

The purpose of this test is to illustrate ways to make health insurance more affordable for the average consumer.

Our test family lives in a middle class zip code in greater Atlanta. The parents are early 40's with two children, including one of college age. Everyone is assumed to be healthy.

The family visits the doctor about 8 times per year and no one is on medication.

They are given a choice between two plans (out of approximately 1800) from a major carrier. These are not the most expensive nor the least expensive plans.

One plan is $393 while the other is $838.

The lower priced plan has no copays and a $5,000 deductible. The higher price plan has doc & Rx copays and no deductible.

Given the choice between these two plans, most consumers would opt for something similar to the higher priced plan, especially if money were no object. Even when they pay the full premium and all out of pocket costs themselves, most will opt for a variation of plan B over the other plan.

If their goal is to maximize total health care dollars, they failed the test.

Carnival Monday

The Carnival of Personal Finance is up, hosted this week by Million Dollar Journey. It's in the "Top 10. and then all the Rest" model. With almost 90 submissions, it's an amazing effort.

I love to play Scrabble (the word game), but never thought of it as a metaphor for financial decision-making. At Bargaineering, host Jim brings the two together.

It's Enough to Make You Sick . . .

One of our local weeklies ran an article on the woes of our taxpayer funded, "charity" hospital. Grady Hospital has been in the news quite a bit over the last few years and even more so as they face a serious funding crisis.

While the issue of Grady is local, it is reflective of what ails many of the public supported hospitals in cities all across the country.

Too many non-paying patients.

He’s supposed to be on medication for high blood pressure, but hasn’t taken it in several months because lately he can’t afford it. He’s self-employed and, like many carpenters, roofers, plumbers, electricians, painters and contractors everywhere, he doesn’t have insurance. Fully 33 percent of Grady’s patients are uninsured.


There are many ways to control hypertension, including meds. Hypertension meds are among some of the lowest priced and many are on the $4 generic list at Wal-Mart & Target.

Additionally, there are programs available for those who cannot afford medication that allows them to receive their meds at little or no cost.

The problem with Grady is the same problem that would affect any business. When fully one third of your clients do not pay their bills any business would have a problem staying open.

I found this comment noteworthy.

some hospitals and health care systems, like Grady, are fighting for their lives, while private American health care systems open state-of-the-art hospitals overseas.

Private American health care systems are operating overseas hospitals.

This is going to take a bit more research.

And what about this two-tier health system?

Overseas, the poor go to public hospitals, so the private American outfits cater to burgeoning middle classes—like India’s call center workers, who are provided insurance by their American employers.

Michael Moore must have missed this in his documentary.

the greatest irony of all may be how Medicaid, a national health coverage plan designed to pay for the care of those who cannot pay for it themselves, has become so overburdened and so politicized that even on its best day, filing for Medicaid reimbursement is a bit like playing the lottery

Ah yes, Medicaid. The other taxpayer funded health care system that politicians want to expand.

But much of what ails Grady (and perhaps other public hospitals as well) is poor management.

if an emergency room treats someone whose case is deemed by the CMOs not to be an emergency, the hospital is paid what is called a triage fee—only about $50, says Kevin Bloye of the Georgia Hospital Association—no matter how much time was spent with the patient or how much was done for him.

How many non-emergency situations are being treated at Grady (and other hospitals) where the reimbursement by the taxpayer is only $50?

The apparent waste of taxpayer dollars is enough to make you sick.

Felony or Fundraising?

Seems the Florida Atlantic University (FAU) has a problem: not enough money.

Now, granted, that's not a situation unique to FAU, but they've proposed a somewhat unusual (but not unheard of) fundraising scheme:

"(T)he school pays the premiums on life insurance policies for select boosters, who then name the university as beneficiary. The booster eventually shuffles off this mortal coil, leaving behind an endowed chair."

I recall some years ago a similar program at one of our state universities: in exchange for lifetime 50-yard line tickets, alumni bought life insurance policies naming the school as the beneficiary.

And churches (and, of course, synagogues) do this all the time. It's an inexpensive, guaranteed way to build a nice endowment. Using life insurance for charitable purposes goes back a long way, and is perfectly legit.

In fact, I also mind a time where I proposed a slightly more grandiose scheme: buying group term life policies on the entire membership, and including the premiums in the annual statements. Alas, I got no interest from any of the carriers I approached (which was probably just as well; there are a number of ancillary issues that accrue to this idea).

But this is different. It seems to me that it's much more analogous to Stranger Owned Life Insurance (aka "Dead Peasant Insurance"), which I had thought had already met its own demise. In the typical case, one applies for a life insurance policy, naming the charity as the owner, premium payor and beneficiary. This is important, because one wants to avoid any "incidents of ownership," which would negate the tax benefits of the arrangement. Each year, one donates to the charity an amount equal to the premium; the charity then cuts a check to the insurer. At one's demise, the proceeds go directly to the charity.

Win, win, win.

But it looks like the FAU model (which, in turn, is based on one "pioneered by Oklahoma State University") has the university simply paying the premiums without any such donation to cover the cost. In a way, it's a good deal: the premiums should amount to a fraction of the death benefit. One supposes that there is some kind of quid-pro-quo tax break for the insured, but that's beyond my purview.

Jac Wilder VerSteeg, deputy editor of the Palm Beach Post, has another concern:

"But hold up. There is a real risk that the designated donors would be inconsiderate enough to live so long that the university would pay more in premiums than it would recover upon the donor's death. Before undertaking the life insurance scheme, FAU officials want to satisfy themselves that the risk of losing money is minimal."

It is minimal; in fact, it is non-existent: properly structured, the sum of the premiums paid can never equal (let alone exceed) the face amount of the policy. All the university needs to do is to make sure that the folks designing the plans know what they're doing.

I wonder if Bob or Bill are Florida licensed.

"Universal Coverage:" A Most Brilliant Analysis

[Welcome Industry Radar and City Journal readers!]

No, not ours: Peter Huber's. IB readers may recall our last post about one of his articles, "Cherry Garcia, Lipitor & You (and me, too!)." Well, as terrific as that article was, his recent IBD piece on Universal Care is even more insightful (and that piece is actually a shortened version of one in City Journal).

Since starting this blog (coming up on 3 years in a coupla months), I've read literally hundreds (if not thousands) of articles and blog-posts on health care and health insurance. Some have been really, really good. And some have been, well, awful.

This, though, may be the most brilliant, perfectly crafted, well-reasoned article on the folly of "universal care" yet. Now, with a set-up like that, there's a real danger that any given piece will fail to meet one's expectations. But having re-read it now for a fourth time, I really doubt that will happen.

Okay, to the chase:

One of the most important observations that our Mike Feehan has made, and which has become something of a mantra for us here at IB, is that "health insurance costs increase because health care costs increase." While this may seem self-evident, many people continue to conflate the two, and others still believe (erroneously) that health insurance drives health care. The point of Mike's assertion is that, unless and until we find a way to control health care costs, we're never going to rein in health insurance costs.

And that is completely of a piece with Peter's observation that "(t)he cost of health care has a big, direct impact on both the cost of labor and the marginal tax rate. If California defies the new medicine's economics by requiring insurers to ignore everything but age and geography, firms can flee to Texas or Shanghai." Think of health care costs as a balloon: squeeze it at one end, and the air moves to the other. Squeeze it in the middle, and the air moves to the sides. But it's still the same volume of air: you've done nothing to shrink the size of the balloon (or the amount of air inside of it, for that matter).

What Universal Coverage (UC) doesn't do is to contain costs; it simply controls access. Anyone who's bought gloves knows that "one size fits all" is only half a sentence: the rest is "but not very well." And so it is with UC, or socialized medicine, or whatever the current buzzword happens to be. Put more simply, "universal health requires steadfast public support...[but] you have the pedestrian problem of costs that rise forever."

A key element in Peter's deconstruction of UC is that it fails to take into account "the human factor." That is, the choices we make, and whether or not we're ready and/or willing to live with the consequences of those choices. An example: "For health-conscious people, skipping the Cherry Garcia may be difficult, but it's cheap, and Lipitor at almost any price is much cheaper than a heart attack."

The point is, it costs very little (in fact, it's a net savings) to just not buy (or eat) a carton of ice cream (I prefer Graeter's), and the cholesterol pill is relatively inexpensive. Of course, downing the whole pint (or quart) isn't terribly expensive either, but the results are part of what continues to drive up health care (and hence health insurance) costs. But unless we pass laws banning ice cream ("if double-fudge swirl is outlawed, only outlaws will have double-fudge swirl"), folks who don't think these things through, or have direct costs (like higher deductibles and/or premiums) aren't going to be motivated to change their behavior. It will fall to the rest of us to "rescue" them.

The problem with that, of course, is that, as Peter observes, "(t)he health-careless skip only the pill, not the ice cream, and end up in desperate need of what helps the least and costs the most." And, eventually, those who are what Peter calls "health-healthy" will begin to resent, and resist, paying for the poor choices their less responsible fellows make.

In short [ed: yay!], a Universal Care system must find a way to control the costs of care, or risk major shortages (which we've documented many times here at IB). But such a system, which is mandated to cover everyone, simply can't do that by fiat, and so costs will continue to rise. Again, think of the balloon. And it affects other segments of the economy, as well: "Efficient labor markets require efficient health insurance, which will be found only where actuaries are allowed to find out as much as the rest of us can, and craft policies accordingly."

But in a nationalized system, where does one go? Well, those that can afford to will take advantage of the burgeoning world of "medical tourism." But what of those who can't?

In the insurance business, we see a certain phenomenon play out over and over again: XYZ Mutual sells health coverage. Thousands of folks (most of whom are reasonably healthy) sign up. As the years go by, people have claims, and the rates go up. Pretty soon, the rates go up enough that most (if not all) of the healthy folks find cover elsewhere, leaving the sickest (who can't move) in an ever-shrinking pool with ever-increasing claims. We sensitively call this the "Death Spiral."

Is that what awaits us at the end of the UC tunnel? Peter has some thoughts on this, as well (although he doesn't use that particular term). As they say, read the whole thing.

Webbies '07 (Yay!)

After a one year hiatus, InsureBlog once again made the cut. We are thrilled to have been one of 10 Finalists, out of some 1700+ eligible blogs.

Voting has ended, and it looks like we ended up in 6th place. Not bad for a "niche" blog on insurance.

Thank You to all of our great readers and supporters. But most of all, Thank You to my talented and prolific co-bloggers: Bob Vineyard, Mike Feehan and Bill Halper.

Cavalcade of Risk #38 is up!

Finance-blogger SuperSaver hosts this week's edition of the Cavalcade of Risk. Please be sure to check it out.

And please consider hosting a Cav yourself: it's fun & easy, and a nice traffic bump (really!).

To host, just drop us a line.

Medical Tourism in the Sceptered Isle

A recurring topic at IB over the past couple of years is a phenomenon known as “medical tourism” – basically, patients who seek medical care outside their own country. Medical tourists take advantage of the high-quality care, and the technology for delivering such care, that is increasingly available around the world - including many so-called third world nations – at a fraction of its cost at home. Not a surprise that up to now, medical tourists tend to be wealthier patients and tend to come from wealthier nations.

Some nations – especially Jordan, Bahrain, Qatar – are spending billions to construct first-class medical facilities, and have contracted with high-profile U.S. health care organizations – Harvard and Johns Hopkins Medical schools, for example, and Cleveland Clinic – to help equip and staff the facilities, and ensure the delivery of a “world-class” level of care. Nations such as India, Thailand, South Africa, and others too have built a fair number of truly excellent health care facilities that also cost far less than in the U.S. and perhaps surprisingly, less than in Western Europe as well. And they deliver arguably equivalent care.

Medical tourism among Americans has been steadily growing even though it still represents a tiny fraction of total Ameerican spending on health care.

But now comes news that medical tourism is rapidly growing in the U.K.

This should be a surprise to most Americans. In the first place, most Americans believe care in the U.K. is “free”. No Brit needs to seek care in another country in order to save money. And in the second place, most Americans believe that access to health care, the quality of health care received, and finally the resulting health of the British population are superior to the U.S. And in large part, such superior outcomes are believed to be a natural product of the single-payer U.K. system. Nevertheless, medical tourism is present, and growing rapidly in the U.K. That’s surprising – at least to me it is.

As reported in the London Daily Mail, there seem to be two main reasons. First reason: to escape the waiting list for service. The average waiting time for specialist or hospital care, after one has seen one’s GP, is more than 4 months. In the U.S. we hear a lot of objection that the queues are imaginary. But medical tourists suggest that the queues in the U.K. are not imaginary after all. Second reason – and more recently: to escape superbug infections in NHS hospitals. Both reasons involve, at least as reported in the Daily Mail, the desire to “escape” the NHS.

The head of a British patient advocacy group believes that Medical tourism reflects “shrinking public faith in the Government's handling of the NHS”. The shadow health secretary (the shadow knows) says the growth in medical tourism figures are “a terrible indictment of government policies” that were “undermining the efforts of NHS staff”. In other words, the blame is being aimed directly at the government – not at doctors or hospitals, or other clinical staff for that matter.

And this is a very important distinction. Brits are not afraid of their doctors. But they seem to be losing confidence in their health care system. More people seem to believe their government is mismanaging NHS and this naturally leads to fear of NHS. So the growing phenomenon of medical tourism may well reflect the growing dissatisfaction with government mismanagement of the health care system. Voting with your feet, I guess you could say.

One department of health official stated that “almost half of patients were treated within 18 weeks of seeing a GP.” Almost half, eh? So the median wait is even longer than 18 weeks? The same official added “Most people who had hospital care did not contract infections.” Is it reassuring to be told that "most” people won't be infected by the hospital they are in? Government statements like these make it easy to understand why people are mistrustful.

The incidence of medical tourism in the U.K. is still quite small but I think the important questions are: how soon can the government restore public confidence in their ability to manage NHS? And how exactly will they go about it?

And For Everything Else, There's . . .

When making out your holiday gift list, here is an idea you probably overlooked.

Orthopedic shoes.

Or maybe a colonoscopy.

Perhaps a Botox treatment is more your style.

How is a fella supposed to know what to give that special woman in his life? How about a Visa gift card from Highmark?

Pittsburgh health insurer Highmark Inc. is selling a Healthcare Visa Gift Card from $25 to $5,000 to cover prescription co-payments, elective surgery, contact lenses and gym membership.

How thoughtful.

Highmark believes that the card fills a need for many people who want to help others -- from college students to baby boomers -- with various expensive health-related needs, but feel uncomfortable about offering cash.

I can dig it.

"I wanted to give something more than just a card and cash. How about a high colonic to improve your attitude, honey"?

Now isn't that special?

Kind of gives the traditional Christmas goose a new meaning.

How to Save a Billion or Two

Need to save a few billion on health care?

Become a wise shopper and be more proactive.

Approximately 18% of health care dollars are spent on prescription drugs. Many of those are maintenance meds that, in many cases, are for conditions that could be prevented with lifestyle changes.

So how do you win? Ask your doc about switching to generics or other therapeutic equivalents.

But be aware you may have a fight on your hands.

scientists and doctors say that for most of the 16 million people in America who take drugs to reduce cholesterol, the low-priced alternative will work as well as the name-brand medicine — Lipitor, which is made by Pfizer and is the nation’s most widely prescribed drug.

"Low priced alternatives work as well".

Keep that in mind.

While Lipitor itself is not available as a generic, a very similar drug made by Merck, Zocor, lost its patent protection last year. The generic version of Zocor, simvastatin, is now much cheaper than Lipitor, leading insurers to press doctors and patients to switch

How much can you save?

A 30 day supply of Lipitor 20 mg runs around $112 or almost $3 per day.

A 30 day supply of Crestor runs $92.

Lescol, about $67.

Lovastatin, $20.

What could you do with an extra $92 in your monthly budget?

When you are spending the carriers money (which is really your money) something odd happens. Very few really care how much medicine (or anything else) costs.

Change to your money, (such as with a high deductible health plan), and attitudes change.

Can 16M people taking cholesterol meds make a difference?

Absolutely.

Become proactive about your health care. Become a wise shopper. Stop making the carriers and drug companies wealthy at your expense.

Monday Health Roundup

■ What do chicken wings, red beans and rice, and gall bladder surgery have in common? Well, they all go better with capsaicin.

So what's capsaicin?

It's only the hot new wonder drug [ed: "hot?" Ugh!]

The product that actually makes hot wing sauce hot may have other uses, as well:

"Doctors are dripping the chemical that gives chili peppers their fire directly into open wounds during knee replacement and a few other highly painful operations."

Ouch!

Well, not really. The thinking is that it actually acts to numb the nerve endings, and thus reduce (or even eliminate) the pain. And it's not just for knee surgery, either:

"Harvard University researchers are mixing capsaicin with another anesthetic in hopes of developing epidurals that wouldn't confine women to bed during childbirth, or dental injections that don't numb the whole mouth."

I'm sure there are a lot of great lines there, but we'll take a pass.

■ We shift our attention now from chili peppers to Tar Heels, as we learn that North Carolina has taken the lead in successfully, and quickly, treating heart attack victims:

"The reason is the nation's most ambitious statewide project to redo how serious heart attacks are handled. Paramedics, doctors and 65 hospitals put aside powerful individual interests like money and control, and focused on giving faster care."

Turns out, it's speed, not drugs, that can often make the difference between survival and death. Angioplasty is the procedure of choice, but is often unavailable in rural areas, or at least in a timely fashion. So almost 5 dozen smaller hospitals agreed to forward their heart attack patients to larger ones, which could more easily and quickly perform the life-saving procedure.

Wonder if they used chili peppers to ease the pain?

■ Thinking about a move? Well, if you like your maple syrup real, and your health terrific, then The Green Mountain State is the place to be:

"After four consecutive years of being crowned the healthiest state, Minnesota dropped to No. 2 behind Vermont for the title this year, according to a report released Monday by the United Health Foundation, a non-profit health advocacy group."

The ranking's based on a number of criteria, including obesity rates, infant mortality and high school graduation rates (although it's unlcear what that last has to do with overall health). Vermont spokescritter Sharon Moffatt credits her state's high score on such things as anti-smoking programs, among others.

Kudos to our 14th state!

An Idea With Promise

The Dodgeville dairy farmer had been paying about $1,400 a month for coverage for her family. But a new health insurance cooperative for farmers dropped her payments to nearly half that.

Cutting premiums in half.

All applicants accepted regardless of health.

Sounds great.

The Farmers' Health Cooperative of Wisconsin say it's growing fast. It's the nation's first such program and organizers say other states should consider adopting it.

Why not?

So far 1,600 farmers have signed up. The group's goal was 1,000 within the first year.

The plan launched in April. They enrolled 60% above their target in 6 months.

This has all the markings of a plan doomed to fail if not properly managed.

There is no magic to this industry. You can't offer something for half price and continue to survive.

Stupid Association Tricks

Recently, I was invited to give a presentation to a group of professional medical office managers (and some of their physician-employers). This was part of a conference on health care in general, and I was tapped to discuss the future of health care financing. For those who are interested, the presentation (in .pdf form) is available here.

As part of the arrangements, I agreed to forego my normal fee for such events for the opportunity to sup with other speakers and the association's leadership at their pre-conference banquet. When that offer was withdrawn, I agreed (perhaps foolishly) to reduce my fee, motivated primarily by the opportunity to network with what I was told would be over 200 office managers. This seemed to be a good way to meet decision-makers and advisors.

Alas, this "golden opportunity" turned out to be more of a lead balloon:

Once I arrived at the conference center (which was quite nice), I wandered around for a few minutes, trying to find the folks in charge. I finally met up with a couple, who seemed to have no idea what was going on. I was invited to attend the keynote presentation (where I did sit in for a bit), and finally found the room where I was to give my presentation (again, the facilities were first-rate).

I should have known something was amiss when I saw that the signs which announced the topics of the break-out sessions had mine completely wrong, as was the notice outside "my room."

Nonetheless, I had a nice crowd (maybe 30 attendees), and the session seemed to go quite well (in fact, the keynote speaker herself stopped in, and ended up staying for the whole thing). We actually ran long, because there were a lot of (good) questions and discussion. I stayed for lunch, and departed.

And that was the last I ever heard from the "leadership" of the association.

Well, that's not quite right: the professional who had invited me in the first place sent me a very nice email, apologizing for the lack of professionalism, and informing me that the folks in charge had decided not to pay me for my services.

Or send me the results of the evaluations.

Or even a Thank You note.

I did send them a follow-up letter, asking for payment, but have received no reply.

There's not much I can do about any of this, of course. One supposes that there are legal remedies available, but I'm reluctant to go that route (who has the time?). So, I'll chalk this up to "lessons learned" and move on.

One bright spot: the luncheon was delicious.

Piling on the MVNHS©

Quick, to which health care system is this quote referring:

" Nearly half of those questioned by the Patients Association said they wanted to see further cuts in waiting times for treatment, an urgent reduction in infections such as MRSA and Clostridium difficile (C. diff) and an increase in the number of doctors, nurses and other healthcare staff. "

If you answered "England's," you win a valuable prize.

We've long referred to the British healthcare system as the Much Vaunted NHS©, and watched as it slowly (but surely) disintegrates. There are, of course, those who think such a system would be just peachy here in the former colonies, but we have our doubts.

Latest case in point:

"The survey comes as new figures reveal that last year about 70,000 Britons spent more than £315 million paying for treatment in overseas hospitals and clinics to escape long NHS waiting lists and high rates of infection."

Ooops.

Granted, we recently blogged on this phenomenon, as a sort of counter-point to those who pooh-pooh our own system as somehow "broken." There's no question that our system is far from perfect, but a move to gummint-run healthcare is apparently no panacea.

As Keith Pollard, blogging at Treatment Abroad, observes:

"Despite huge investment in the NHS over the past 17 years, patients from the UK are voting with their feet and travelling abroad."

And there's this: almost a quarter of those surveyed support "a tax deductible insurance policy as a way of paying for treatment."

Well heck, so do we!

But that's another post.

New Consumer Tool

The website, outofpocket.com is a platform for collecting and sharing health care prices. The directory currently contains over 100,000 prices collected from several different sources:

Consumer Generated Content: Consumers anonymously post prices they paid for routine health care services, (including MRIs, mammograms, X-rays, lab tests, vaccinations, dental, vision and office visits), along with their personal recommendations on the provider

Providers that Disclose Pricing: Providers are invited to submit true prices for their services for inclusion in the directory

Government CMS: Medicare price data for common medical procedures has been loaded in the directory

Claim data from self-insured employers

Soylent Green Redux?

Fans of the cult 70's sci-fi "hit" may recall that one of the plot points was euthenizing senior citizens. While the Much Vaunted NHS© may not espouse that most literal solution, it certainly sent a powerful, difficult-to-miss message that its seniors are "expendable:"

"A 75-year-old man was forced to spend his life savings on a vital hip operation after the NHS cancelled his appointments four times."

The MVNHS© determined that Edward Crane actually needed the surgery, and went so far as to refer him to Queen's Hospital (a figure of speech, almost certainly: I doubt Her Highness was actually on tap to perform the procudure). But the facility kept cancelling and rescheduling, until Mr Crane was left with no choice but to self-finance the entire cost of the operation.

I think his daughter said it best when she observed "(h)e has nothing left now. It's not fair how the NHS treats old people."

Will our politically-savvy and active senior class (as in "mature") stand for such treatment as part of a gummint-run system here?

Only when we pull the scalpel from their cold, dead hands.

Cavalcade #38: Submissions Due

Just a reminder that submissions for next week's CoR are due this Monday (the 5th). Our host, SuperSaver , asks that you PLEASE include:

■ Your blog's url

■ Your post's url

■ The post's trackback URL (if available)

■ A (brief) summary of the post

You can submit them via Blog Carnival or email.

Don't forget: we still have hosting slots available. Please drop us a line to reserve yours.

BTW: Law-blogger Eric Turkewitz presents the Personal Injury Law Round-Up #35. Interesting stuff.

All in Your Genes

Scientists at Case Western Reserve University have genetically engineered mice that outrun, outlive, and out-eat ordinary mice while staying lean, light, and fertile well into old age.

Mighty mouse!

Running on special treadmills designed for mice, the genetically engineered mice left ordinary mice in the dust.

Sounds like something from a sci-fi movie.

The genetically engineered mice ate 60% more than the ordinary mice, but they were lean and light, weighing half of what normal mice weigh with 90% less body fat.

Give me some of that.

A major unanswered question, Hanson's team notes, is what brain changes accompany the genetically engineered mice's hyped-up activity.

My guess is the mice can't resist passing by a mirror without taking an admiring look . . .

Captain Obvious to the Rescue

Okay, I admit it: I listen to the Bob & Tom Show on my way in to work most mornings. For those unfamiliar with B&T and the crew, suffice it to say that they are irreverent, not-quite-obscene, and (usually) hilarious. One of their on-going "bits" is a call-in show whose host, Mr Obvious, has to deal with the same dense, utterly clueless caller every time. From how to cook a Thanksgiving turkey ("first, it must be a dead turkey") to an errant garbage disposer, it's fun to hear his exasperation.

But it's not so fun when we have to actually pay for answers that Mr Obvious could easily have handled for free. Recently, Bryce Edmonds wrote about 10 such studies for MSN. It's a veritable "who's who" of misguided studies that ostensibly rational scientists undertook (and for which they were paid). Among their brilliant findings:

■ "Scientists have proven that, yes indeed, air pollution is bad for you."

■ "In the September Emergency Medicine Journal, researchers reported that traveling longer distances in an ambulance meant you were more likely to die before you got to the emergency room."

And this gem:

■ “It is a matter of common sense that a person is easier to recognize when close than when far away.” (But that didn't stop the National Institute of Mental Health from underwriting a study to test that)

In case your blood pressure is running a little low today, go take a gander.

But if it's on the high side, you should know that "(m)eetings stress out employees," so you should probably skip the next one. Really!

HWR: The Anti-Halloween Edition

You know us wonks and geeks, we just have to be different. So while it seems that every other "carnival" is touting scary monsters and yummy treats, we're oiling up our sliderules and adjusting the paperclips holding our glasses together. November 1 is actually famous for more than just All Saints Day, and (wonk that I am), we'll be exploring its not-so-famous associations.

Before we start, however, there’s some cobwebs I’m motivated to clean up:

First: We got a LOT of submissions from what my pal Julie calls “splogs” (spam blogs). These can be either transparently commercial endeavors, or folks who just submit to every carnival. I deleted them mercilessly.

Second: If you’ve ever hosted a carnival (HWR, etc), you know that there’s a LOT of reading to do. I suspect that I speak for most (if not all) of my fellow hosts when I tell you that if you didn't care enough about your entry to include a summary, I didn't either, and it was zapped.

Third: We all think everything we write is Pulitzer prize-worthy. It’s not. Please don’t submit more than one entry per blog. I was VERY nice this time, and picked the one I deemed most appropriate. Next time I host, I won’t be so generous.

Okay, that’s off my chest (and the axe is out of my skull), so on with the show.

On This Day*:

■ In 1805, Napoleon Bonaparte invaded Austria. And today, Jon Swift presents Fair Game, at his eponymously named blog. Jon opines that what makes conservatives like Malkin and Macsmind different from liberals like (Ezra) Klein is that conservatives would rather struggle and be faced with terrible health care choices than to have no choice at all, which is what would happen under socialized medicine.

■ In the year 996, then-Roman Emperor Otto III issued a deed to the Bishop of Freising. This is the oldest known document using the name Ostarrîchi (Austria in Old High German). This morning, Jimmy Atkinson presents 5 Little-Known Giant Health Care Issues Facing the United States at OEDb: Nursing Online Education Database.

■ In Mexico it’s the Day of the Dead (BOO!). Here at HWR, PatKing presents Getting rid of the dead weight of old regulation. Pat, blogging at Healthcare $$ and Sense, discusses how we keep adding new laws and regs, but rarely delete the old ones.

■ In 1973, at the height ot the Watergate Scandal, Leon Jaworski was appointed as the new Special Prosecutor. Today, David Harlow presents Rhetoric vs. reality, or, the not-yet-ready-for-prime-time universal health plans: Britain's NHS, Medicare (for All), and the FEHBP, presented at the HealthBlawg.

■ Way back in 1512, Michelangelo’s masterpeice, the ceiling of the Sistine Chapel, was exhibited to the public for the first time. In what some might call a modern masterpiece, Jason Shafrin blogs about Therapeutic non-adherence: a rational behavior revealing patient preferences. At the Healthcare Economist, Jason avers that "drugs should be judged not only on their efficacy, but on the degree that patients will comply with the treatment."

■ In 1920, when Joe Paduda was still a young man, the American fishing Schooner Esperanto defeated the Canadian Schooner Delawana in the First International Fishing Schooner Championship Races in Halifax. Legend has it that Joe lost almost $5 betting on the Canooks. Today, though, he presents The Faux Canadian. Observing that there's lots of good info out here in the blogosphere, but that there’s also lots of misinformation, Joe deconstructs and debunks [ed: we call that “fisking"], an email from an alleged Canadian, one who is none too fond of their health care system.

■ And in 1755 , the terrible Lisbon earthquake nearly destroyed that fair city, killing between sixty and ninety thousand people. Daniel Goldberg discusses a modern day “healthquake” in his post ON MRSA & Prevention.

■ Dateline: Desert Rock, Nevada. In 1951, American soldiers were involuntarily exposed to an atomic explosion for training purposes. And today, David Williams presents the latest developments in the Avastin/Lucentis saga. Over at his Health Business Blog, David had asked "did the FDA really force Genentech to withhold Avastin from compounding pharmacists?"

■ In 1886, the Ananda College, a leading Buddhist school in Sri Lanka, was established with 37 students. Although he wasn’t one of them, Zagreus Ammon has some thoughts on the concept of Alternative Medicine for Underserved as a Public Health Problem.

■ In 1957, Michigan's Mackinac Bridge, the world's longest suspension bridge between anchorages at the time, opened to traffic. Today, Lisa Emrich, blogging at Brass and Ivory, continues the alt.med theme. Her own experience with drug interactions forms her thesis about the value of what she calls "integrative medicine."

■ The first medical school for women opened in Boston, Massachusetts, on this day back in 1848. And over at the HealthBeat blog, Maggie Mahar thinks that The Bay State is a terrible venue to try out Universal Heath Care coverage.

■ In 1970, a fire at a dance hall in France killed 144 young people. Today, fires are raging in California, and Michael Millenson (President of Health Quality Advisors LLC in Highland Park, IL.) is guest-blogging at Matthew Holt’s place. Mr Millenson thinks he’s found a connection between the California fires and health care reform.

■ November 1, 1955 saw the The Famous Flames, a band featuring James Brown, record "Please, Please, Please" at a radio station in Macon, Georgia. Today, New York attorney/blogger Eric Turkewitz comments on an article in the Archives of Internal Medicine which claims that communication is a major cause of medical malpractice, especially among staff in training.

■ In 1963, The Rolling Stones' released their first single: 'I Wanna Be Your Man.’ And rockstar health-blogger Dr Roy M. Poses looks into some potential conflicts of interest surrounding PBS’s recent series on “the Mysterious Human Heart.

■ The worst rapid transit accident in US history occurred under the intersection of Malbone Street and Flatbush Avenue, Brooklyn, New York City on this date in 1918. But Michael Cannon thinks that’s nothing compared to the dangers of Universal Coverage.

■ In 1876, New Zealand's provincial government system was dissolved, which led to some major disruptions. Workers Comp Insider Julie Ferguson discusses the initial impact of the Southern California fires on businesses and suggests that employers prepare to deal with post-traumatic stress reactions from employees who suffered their own major losses and disruptions.

■ And finally, on November 1, 1941, iconic American photographer Ansel Adams took a picture of a moonrise over the town of Hernandez, New Mexico. It would become one of the most famous images in the history of photography. Which has nothing to do with my post, but Mr Adams is a fave of my eldest daughter. My post, on what I call Open Source Health Care, is about whether we're using the wrong models in determining how best to finance health care.

Thanks for playing along, and be sure to join us on November 15 at Maggie Maher’s place.

*Factoids courtesy of Wikipedia.

The Answer Man

Q. I have never heard of (insert carrier name here). Will my doctor accept them?

A. That's OK. The carrier has never heard of you either.

Does your doctor accept cash or checks? If not, you may have a problem.

Most likely the plan you are considering is tied to a managed care network. If your doc participates in the network they are usually obligated to accept assignment of benefits and file claims on your behalf.

As long as you deal with a major carrier and understand the benefits & plan limitations you should not have a problem and neither will your doc.


The Answer Man may or may not become a semi-regular item. Many of the questions are some we have fielded from real clients. If you have specific questions you may submit them to us for consideration.