Tuesday (Healthy) Food Pyramid Update

It's been a while since we've visited our own special IB Food Pyramid , and today brings us two interesting items:

■ First up, erstwhile political pundit (and baseball afficianado) George Will is of the opinion that not only is beer a desirable commodity, it is an essential one. He opines that "No beer, no civilization." I'm not sure I'd go that far (on the other hand, I'm not sure I wouldn't go that far, either), but Will makes a strong case:

It is Will's contention that, once we grew from the hunter/gatherer stage into an agrarian society, our living arranegments changed dramatically. Where once we had roamed the plains (or veldt, or wherever), we now had the ancient equivalent of "gated communities." This led, unsurprisingly, to urbanization, and a host of new challenges, water-borne diseases among them. And how better to guarantee the safety of that which we drink than by purifying it? And what better process than by fermentation, which leads to the anti-bacterial qualities of our favorite brew.

And I hear it tastes pretty good, too!

■ Quick: which is healthier for you, bacon or fish? Not so fast, pardner:

"Farm-raised tilapia, one of the most highly consumed fish in America, has very low levels of the beneficial omega-3 fatty acids and very high levels of omega-6 fatty acids, a potentially dangerous fatty acid combination...Tilapia has higher levels of potentially detrimental, long-chain, omega-6 fatty acids than...and even pork bacon."

Ouch!

(Of course, the article fails to mention how it compares to the turkey bacon that is regularly consumed in our household)

And it gets worse for folks with heart disease, arthritis, even asthma, who may be thinking "hey, I'll have the fish sandwich instead of the BLT." Unfortunately, that would be a poor choice. So while eating fish per se may be a healthy choice, it's important to select a healthy fish (such as salmon or tuna) to begin with.

■ And in a completely unrelated update:

Regular IB readers may recall the ongoing saga of the Sleazy Seniors, whose scheme to collect the insurance on homeless men they murdered was eventually cracked. Last we heard, they had pled "not guilty" and were awaiting trial.

Well, here's some good news on that front:

"Two elderly women were sentenced to life in prison without parole Tuesday for murdering two indigent men to collect insurance policies taken out on their lives."

Of course, given their advanced ages (75 and 77), one wonders just how long that sentence will actually be. Still, it is justice of sorts.

Dr. Shill

Have you ever considered buying insurance to offset the high cost of doctor visits?

Have you considered buying insurance from you doctor?

Apparently some doc's are peddling insurance to cover the cost of their fee's . . . in Canada.

So what happened to free health care?

Apparently free isn't good enough.

In Ontario you can buy pet care insurance, but not health insurance. But it appears things are about to change.

Since 2000 the College of Physicians and Surgeons of Ontario (CPSO) has approved a health care insurance vehicle for administration, quaintly referring to it as a ‘block fee’. As a result, Ontarians can purchase insurance that will cover their doctor’s notes stating that they are too ill to attend work because they are waiting on a list to get treatment.

So you can't buy health insurance but you can bribe your doc to say you are too sick to work.

What kind of system is that?

What they can’t buy is insurance that will cover the actual care needed. This is because most medical treatments are covered by OHIP, when and if a service is finally performed.

When and if . . . a service is finally performed.

That's reassuring.

The doctor selling his own private insurance product lists 23 administrative services for which he charges fees ranging from $11.72 at the low end for telephone prescription renewals to the high end of $150 for the filling out of forms for a physical required for a driver’s license.

Buying insurance for an $11.72 item.

Of course that is in Canadian dollars . . .

The marketing and price plan are clever giving consumers a choice between the premium family insurance plan at $130 per year covering all 24 categories instead or an individual standard insurance plan of $65 per year which covers 7 categories of uninsured services.

At $65 - $130 per year I can't imagine the docs getting rich off this.

Nor can I imagine why someone would pay a premium to buy this kind of coverage.

I would think there are much bigger issues . . . like wait times.

Carnival of Personal Finance

Nicole the Budgeting Babe hosts this week's collection of finance-related posts from around the 'sphere. She's got a Top 6 list, and then the rest of the posts follow. Helpful categories and context help make it readable and easy to navigate.

Over at Financial Ramblings, blogger Sean has some interesting insights on auto insurance, including a helpful table to compare different kinds of discounts.

Comments Update (7/14/08)

Good news: We got edit back! So please feel free to comment (the more the merrier).

Coming Up Short

[Welcome Kaiser Network readers!]

A million bucks doesn't go as far as it used to.

Neither does $2,000,000.

But according to CNBC and the Kaiser Foundation, 22% of employer group plans had capped benefits at $2,000,000 lifetime.

Mary Wusterbarth thought her toddler was struggling with an ear infection when she seemed sluggish. Instead, a virus had attacked the little girl's heart, damaging it beyond repair. Brea needed a transplant.

Within three weeks of a 2007 doctor visit, the 20-month-old had exhausted the $1 million lifetime maximum on her health insurance. Her parents have scrambled ever since for ways to cover thousands of dollars in monthly medical costs.

My experience is, it is mostly public plans that have low caps. Private industry usually chooses much higher caps.

Employees who participate in the state of Georgia plan have a $1,500,000 cap.

Setting a low cap is not a cost saving measure. To increase a cap from $2,000,000 to $5,000,000 adds about 5% to the premium.

Kelly and Tom Treinen had an option. They could have chosen a plan with a $5M cap through Tom's business. Instead, they opted for the plan with a $1M cap through Kelly's job as school principal.

Then their son became ill with leukemia.

His treatment called for 10 doses of a chemotherapy drug that cost $10,000 per dose. A 56-day stay in an intensive care unit cost about $400,000.

Michael reached his $1 million lifetime maximum in less than a year. The Noblesville, Ind., family had to issue a public plea for help after a hospital told them it needed either $600,000 in certified insurance or a $500,000 deposit to continue preparing for a critical bone marrow transplant.

$1,000,000 seems like a lot of money. It is, until you need every penny and then some to restore your health.

Mary Wusterbarth, a stay-at-home mother with two other children, thinks legislation on minimum lifetime caps is an excellent idea.

This is not a legislative issue.

Rather, it is a matter of educating the public about health care and its' costs.

It is a matter of Functional Illiteracy.

Functional Illiteracy

Most of us speak English. Some also speak a second language such as Spanish, French, or Southern.

Very few speak insurance.

So when it comes to understanding what you have, or knowing what you need, it is as if you are in a foreign land and no one speaks your language.

When it comes to buying insurance most people are functionally illiterate. Let me give you some real life examples.

Jim is a banker looking for health insurance. He is reasonably healthy, especially having survived a bout with cancer from 6 years ago. His wife takes a common anti-depressant and both children are on acne medication.

When we met, Jim had been turned down by Blue Cross and Aetna. He told me he really liked the Aetna plan and it seemed to be a good fit. I asked a few questions, taking detailed notes, and then told him I thought I could get him approved by Aetna if he was willing to work with me.

It took almost a week, but I did get him and all family members approved by Aetna, but with a slight rate up.

When I called to tell him the good news he thanked me for my hard work. He also told me he had applied with Golden Rule after asking me to help and that Golden Rule had approved him "without the hassle they had felt from Aetna" and had given him a good rate.

When I quizzed him about the offer it became quite clear he had purchased a plan that would never cover doctor visits or prescription medications. As a cancer survivor I was quite surprised he would pick such a plan.

He also paid extra for an annual wellness benefit. The premium runs around $800 per year and he is not allowed to use the benefit during the first policy year. The benefit has a value of around $800 but only if all family members have a physical.

Jim is functionally illiterate.

He bought a plan that can potentially cost tens of thousands of dollars each year if anyone in his family have a major claim. He also paid for something he cannot use for 12 months.

Here is another example.

I recently contacted a lady who had requested assistance in finding health insurance. When I called she said she had already decided on "Atena" and was waiting until Monday so she could sign up with them.

I told her she could sign up today if she liked, and the company was Aetna, not Atena.

When I asked about the plan she wanted she indicated it had a $1250 deductible, doctor copays and Rx coverage. She was unable to find the premium on the Aetna website.

I told her the premium was $194 and the plan did not cover doctor visits or Rx. In essence, she had half a plan and none of the benefits she wanted or needed.

She abruptly cut me off and said she would just wait to talk to someone at Atena who could take her order.

She was functionally illiterate.

The plan has the potential to drain her bank account by thousands each month if she has a major claim. For $14 more in monthly premium she can get a plan that will cover ALL her expenses, including doctor visits and Rx. However, her mind was made up. No need to confuse her with the facts.

I see this quite a bit.

One question that comes up with some frequency is "what is my out of pocket limit"?

The answer is, it depends.

Some carriers include the deductible in setting your OOP (out of pocket) limit while others do not. Your OOP does not include copays and separate deductibles such as for Rx or ER.

About 20% of the individual medical plans sold by major carriers do not include coverage for medication. This is no big deal until you need the coverage.

So how will you pay for Avastin ($50,000 per year) or Erbitux ($120,000 per year) if you contract colon cancer? How about Herceptin ($36,000 per year) for breast cancer?

Functional illiteracy will cost you dearly. Unfortunately, most people find out their plan falls short when a claim is denied.

Oy Canada (Again)!

As has become fashionable, there's a lot of talk about the wonderful world of gummint-run health care. As I mentioned the other day, though, one should treat such wishes most carefully, because "free" things often end up costing a lot. Anyone who's ever adopted a "free" pet knows exactly what I'm talking about. As does Canadian citizen Shona Holmes, whose three year health care horror story began with a brain tumor:

"No one should be forced to travel thousands of miles to obtain quality care. Yet that exactly is what I was forced to do after being diagnosed with a brain tumor three years ago. After my government told me that I'd need to wait four to six months to see a neurologist and endocrinologist, and with my eyesight rapidly deteriorating, I decided to seek a diagnoses at the storied Mayo Clinic."

We've discussed Canadian med-shopping habits before, but these have typically been short jaunts "just south of the border." Ms Holmes had a bit further to travel (Scottsdale, Arizona, to be exact), where she was informed that immediate treatment was necessary. This meant an immediate return to her native land, where she anticipated her "free" national health care system to be waiting with open arms, eager to remove the offending and dangerous growth.

Regular IB readers already know what happened next: she was put on a waiting list and urged to "hope for the best." While that's a wonderful thought, it doesn't typically translate to an actual cure. So, she hopped another flight and flew back to Arizona, where she underwent surgery that successfully removed the tumor and restored her sight. But don't just take my word for it, here's Shona herself:

Shona Holmes (Toronto, Ontario, Canada) from BigGovHealth on Vimeo.

While policy wonks and candidates talk about the idea of government run, free health care, very few (I daresay none) actually address the reality of such systems. And while we see Canadian politicos eschewing the free health care to which they're entitled, and traveling thousands of miles inside the good ol' USA for actual care, I haven't read any stories lately (or, indeed, ever) about folks flying out of Washington National en route to Vancouver for that extra special medical attention.

[Hat Tip to BigGovHealth]

Cavalcade of Risk #56: Submissions Due

Health wonk extraordinaire Michael Cannon hosts next week's Cavalcade of Risk from the hallowed halls of the Cato Institute. Submissions are due this coming Monday (July 14).

Mike asks you to include:

■ Your blog's url
■ Your post's url
■ The post's trackback URL (if available)
■ A (brief) summary of the post

You may submit your posts at Blog Carnival or via email.

Believe it or not, we still have slots available for later this summer. Please drop us a line to reserve yours.

Resource Update

From time to time, we become aware of new sites that may be of value to our readers. Sometimes we stumble across them looking for something else; often we get emails touting this "great new site." Unfortunately, most of the latter variety are more advertising than advice, but there are sometimes pearls to be found, as well:

"I am 34 year old who was rendered T4 paraplegic 5 years ago. I have started a niche health directory called HealthDirectoryMoz because I am passionate about "QUALITY and USEFUL" health related websites.

Through this niche directory, I intend to create lasting value to patients, students & medical professionals and sincerely believe that we can have a mutually beneficial association by being in a link relationship."

Patient-blogging is a valid and valued subset of the medblog community, and this site ramps that up even further, offering relevant, up-to-date information, and accredited by the Geneva (Switzerland)-based HonCode organization.

Do check it out.

UPDATE TO THE UPDATE: Amy at DiabetesMine reports that there's a new prescription drug program for folks without prescription coverage (and who aren't eligible for MediCare). TogetherRxAccess is actually a service of nasty ol' Big Pharma, which continues to confound its most ardent critics.

Dr Rob Hits the Big Time

Fellow medblogger Dr Rob Lambert is interviewed today in the New York Times. Dr Rob maintains that it's actually unhelpful to patients to lecture them about their wait. As counter-intuitive as that may sound, the good doctor makes a strong case.

Mazel Tov!

Flex Plan Dilemna

Bob recently had an interesting email "discussion" with a colleague, and since I was tangentially involved, he's asked me to tell our readers about it (Bob's "out of pocket" today).

The other day, I received this email from him:

"Having a disagreement with another agent over health insurance under a flex plan. Figured your buddy Pete would know. Can an employee who is covering dependents opt out of a plan off anniversary by claiming hardship? Premiums are too much, and wants to change to an individual plan. My understanding is they cannot. Even if they did, I am under the impression they cannot change their contribution (assuming they are pre-taxing premiums or benefits) until the anniversary. Do you know the answer?"

[ed: "Pete" is our colleague Pete Deist, about whom we've written before]

I replied that "on the one hand, it doesn't seem "right" to force someone to buy insurance (hello Massachusetts?!); OTOH, rules is rules, and I've never heard of "hardship" as a qualifying event (or would that be non-qualifying event?).

Probably some arcane Section 125 rule about this.

Really two questions though: plan rules and IRS rules.

I'm going to feel REALLY silly when Pete says "oh, that's an easy one, it's..."

In the event, I forwarded Bob's request on to Pete, and here's his reply:

"Your buddy [Bob] is correct.

The legal: Hardship is not a qualifying event permitting a change in a premium election mid-year. He can drop the insurance but cannot stop the withholding until the end of the year. The practical: I don't know of many groups that enforce this rule as it relates to premium"

One wonders, though, how often this comes up. Perhaps more often than we think.

Second Opinions

So I'm sitting at my desk, working on some quotes, when the phone buzzes: Mary Thomas [ed: not her real name] is on line 2, has some questions about life insurance. If only it had been that simple...

Mary is a soon-to-be retired schoolteacher, as is her husband, Marv. She's 58, he's 67 but still teaching. As part of her retirement package, she's been offered a choice of annuity payouts, and her financial advisor has suggested that she choose the one with the highest payout (monthly benefit), but which will also stop at her demise. He's recommending a life insurance policy that would (essentially) continue the income stream if she predeceases Marv.

This is a fairly common strategy. We even have a term for it: pension maximization ("pension max").The idea is that one can calculate the present value of that income stream, and then insure it with a life insurance policy. The advisor had recommended, and then sold her, a 15 year level term plan. Mary had called me because she had some reservations, and wanted a second opinion from an independent insurance agent.

I was happy to oblige.

My first concern was her advisor's ethics problem. I have nothing against fee-based planners per se, but when that same planner not only recommends, but also sells the policy, that is an insurmountable conflict of interest. Fee or commission, not both. My other concern was the inappropriate policy choice.

Let's talk about that.

Term insurance, which is "pure" protection, has many uses, and I sell a lot of it. It's often heralded (inaccurately) as the "least expensive" form of life insurance. The challenge is that it's a temporary solution: it's good for mortgage protection (20 years is 20 years) or if one's raising a family (in theory, at least, Little Johnny will be out of the house in 20 years or so). But it is not a good choice for more long-term needs (final expenses, estate issues, etc). In this case, the advisor was recommending a short term (or temporary) solution for what is, in reality, a long term (or permanent problem): when is Mary going to die?

We went round and round on that, until I asked her a question: why didn't she look for an annuity choice that only paid for 15 years? Surely that would be a larger monthly benefit, and who knows if she'd even live that long? She hesitated, then replied, "but what if I live longer?"

Silence can be golden.

Mary then asked me what I would recommend. I explained (again) that this was a permanent problem, so I would recommend a permanent solution. Whole life would do the trick, but can be terribly expensive at her age. "Regular" Universal Life might work, but lacks the guaranteed death benefit of Whole Life, and I wasn't too keen on going that route. I offered two suggestions:

First, a newer form of Universal Life, which (as long as the premium is paid) offers a guaranteed death benefit payable to age 120 (although premiums would stop at age 100). This plan had no cash value buildup to speak of, but since that wasn't really a goal here, it didn't matter. What did matter was that it would last as long as she needed it to, guaranteed.

My second choice was also a newer type of plan, a kind of hybrid called Return of Premium term. This plan was built on a term chassis but, at the end of the level term premium (e.g. 15 years) gave her a guaranteed, paid-up policy. Simply put, if she dies in the first 15 years, the full face amount would be paid. After 15 years, a lesser amount would be paid, but no premiums would have to be paid after that 15th year.

I explained that option one was a full, permanent solution to a permanent problem, while option two was a permanent "partial" solution. Either one was clearly (to me, at least) superior to the poor advice given by her financial advisor.

Which one, if either, will she choose? I really don't know. Mary really didn't like to think of this as a permanent problem, and who can blame her? But she called me, so something must have been bothering her about the status quo.

We'll have to wait and see.

Comments Update: Important Notice

HaloScan, the service which currently hosts our commenting system, has disabled the "edit" function, which means that we cannot moderate comments as we'd like.

I'm looking at alternatives (Disqus, Intense Debate, etc), and will have a decision soon. Unfortunately, this means that, for the time being, some comments will not be approved. These will include comments with links to commercial sites (as opposed to other blogs).

I am truly sorry for this, but it can't be helped.

If you'd like to comment on a post, and aren't sure whether it meets the guidelines, please send it to me via email with "Comment" in the subject line, and tell me which post you're commenting on.

Thank you for your patience!

Is Health Care a Right?

How about health insurance? A "Right" is not absolute, but it does provide a starting point, a minimum level of protection. The 1st Amendment, for example, guarantees us freedom of speech, but there are limits (shouting "movie!" in a crowded firehouse, for example); the 2nd guarantees us the right to own firearms, but again there are limits [ed: what, no bazookas?!].

But where is it enumerated that we have a right to either health care, or the means to pay for it (insurance)? We've come to expect access to both, and complain bitterly when either are not available or affordable. And various mechanisms have been developed to guarantee some access to both (EMTALA and HIPAA, for example). But just how far are we willing to go?

Here's why I ask:

"Patients will be able to escape NHS queues by demanding treatment anywhere in the European Union without the prior approval of a doctor, under proposals to guarantee health rights unveiled today in Brussels."

"Guaranteed health rights." Sounds good, right?

Not so fast:

"However, if unpredictable cross-border healthcare becomes a problem, the system could put into place a system of prior authorisation to safeguard the system."

Cross-border health care? Like this?

The Law of Unintended Consequences© (thus far not repealed by our congress) governs these transactions. "Rights" carry with them "responsibility," and we should be very careful what we wish for. When we give up certain rights in favor of others (say, freedom of choice in health care?) there are indeed consequences. We saw this in Massachusetts, and we've seen it in Canada and Britain, and we'll likely see it as it envelops the entire EU.

And what is "it," you ask?

Simply this: when a third party provides a service, you're pretty much stuck with that service, good or bad, until you switch. Take our current system, for example (and yes, I know that we have plenty of readers that would love to give it away). If I don't like XYZ Mutual's service, or network or rates, I can shop around to find one that fits me better. Or if I find that Dr Smith no longer suits me, I'm free to go to Dr Jones. But under a gummint-run system, which guarantees me access to both health care and the means to finance it, certain rules will apply, and I'm no longer free to make those kinds of choices.

So let's go back to the original question: is health care a "Right?"

My people have a (well-deserved) reputation of answering a question with another question, and I won't disappoint: Do we really want to make health care (and/or its financing) a "Right?" Rights, as we've seen, are regulated and rationed, and often lack for alternatives when we don't like the result. And then where do we go?

[Hat Tip: RWN]

A Very Special Grand Rounds

Fans of the popular 90's sitcom "Seinfeld" are treated to a nostalgia-filled, cleverly constructed edition of this weekly collection of medblog posts. With pics, clips and quotes, The Blog That Ate Manhattan presents a fun- and fact-filled 'Rounds.

Over at The Covert Rationing Blog, Dr Rich talks about, well, covert rationing: "The sad fact is that anyone who actually tries to look behind the headlines to figure out why physicians are (or are not) about to get hit with a 10.6% pay cut by Medicare will quickly be swept away by a maelstrom of tangled laws, policies, regulations, interpretations, guidelines, secret committee proceedings, quid pro quos, tit for tats, and “unintended consequences” of both varieties."

Read the whole thing.

Lobbyist's Tricks: Update

Last week, I wrote about the mismanagement on display at the Association of Health Insurance Plans (AHIP), insofar as its Long Term Care Partnership Training program was concerned. After a week of trying, unsuccessfully, to resolve the matter, I was pleasantly surprised this morning: Greg Dean, the Executive Director of AHIP's Center for Insurance Education and Professional Development, "was personally dismayed to learn this morning of [my] difficulties in obtaining a certificate evidencing completion of the AHIP LTC Partnership training program." He was kind enough to attach my (new, official) certificate, thus rendering me "good to go" on the future sales of Long Term Care coverage.

While I appreciate Mr Dean's hands-on resolution, and the fact that he seems to have acted immediately upon learning of the situation, it seems to me rather problemmatic that it took this long for the issue to have finally percolated to his desk. One would hope that the organization will consider this "a learning moment," and begin looking for ways to avoid such problems in the future.

Post-Holiday Carnival of Personal Finance

John at Mighty Bargain Hunter hosts this week's Carnival of Personal Finance. As has become the norm for this weekly compendium of all things financial, it's jammed to the rafters with interesting posts.

Definitely worth checking out, if for no other reason than the interesting American Flag factoids.

Independence Day 2008

Amid all the hoopla, hot dogs and fireworks, let's not forget the underlying reason for our celebration, and perhaps pause a moment to reflect on how remarkable (and unlikely) it is that we're still here, commemorating our 232nd Birthday.

And it started with this remarkable document:

Happy Birthday, America!

Speaking of Independence

FoIB David All asked me to help introduce a new 'Net intiative designed to highlight the true costs and risks of government-run health care. It's just now being rolled out, and promises to become a great resource.

Called BigGovHealth, it's presented by the Center for Medicine in the Public Interest (CMPI). Its mission is to offer "news, information, and first-person experiences and views about government-run health care systems to help educate the public, the media and elected officials about the potential costs and consequences of more government control in health care."

Do check it out.

Pre-Holiday Potpourri

■ First up, we go south, and learn that:

"A state court jury on Tuesday found two major pharmaceutical companies defrauded Alabama in a long-running Medicaid drug pricing scheme and ordered the firms to pay more than $114 million in damages."

Although both companies denied that they'd done anything untoward, the jury disagreed. The alleged scam was not a short term deal, either; prosecutors claimed the scheme ran for some 14 years.

My question is: why did it take so long for this to unravel?

■ Our friends at The Industry Radar and the Kaiser Daily Report tell us that The Grand Experiment (aka Massachusetts Health Care Plan) is in a spot of trouble [ed: you're surprised?!]:

"Since the law was enacted in 2006, the percentage of uninsured Massachusetts adults has decreased from 13% to 7%...the actual cost was $625 million."

According to the article, that $625 million was spent on 355,000 people (some got more than others, of course). And it's only getting more expensive:

"Gov. Deval Patrick (D) has requested $869 million for the program for fiscal year 2009, compared with previous estimates of $725 million." That's a roughly 17% increase. But I thought that this would help "lower" the cost of insurance? My bad.

■ Finally, our Cousins Across the Pond have some advice for us:

"Ad by Brit says, 'You won't better your system with ours' "

Oh.

Turns out, not everyone is thrilled with the MVNHS©; lots of folks are a bit put off by the fact that, for example, some treatments are covered if you live in one area, but not if you live across town. The campaign features folks from Britain, Canada, and Europe, and has a simple message:

"Nationalized care systems...distribute care services and products based on whether it is cost-effective for the government, not whether the patient needs it or it will relieve a health problem."

Sounds about right.