The following guest post comes from Judy Strachan. Judy is a member of the Society of Actuaries and a Specialist Leader of Human Capital Advisory Services Total Rewards at Deloitte Consulting LLP.

“Ask yourself this: Other than medical (or dental) insurance, is there any insurance product on which you expect to make a claim every year? Undoubtedly, the answer will be, “Of course not.”

This is a thought provoking quote from an article by actuary Jim Mange, entitled Prepaid Medical Care And Medical Insurance. This article is part of a series of essays on our health care system which are available on Society of Actuaries’ Web site: http://www.soa.org/library/essays/health-essay-2009-toc.aspx. Each of these essays presents a different perspective on the problems with our current system for providing and paying for medical coverage.

It comes as no surprise, the current health care system is not working for any of the parties in the system; employers, medical providers, health plans and health insurance companies and especially not for the consumer.  More clarity is needed to help solidify a new path for healthcare reform.

For the consumer, the current billing practices of providers and payment practices of insurance companies often result in the highest charges being applied to the individuals least able to pay, the uninsured. Even for the insured, understanding the plan benefits, the provider bills and the claim payment process is a major challenge! Personally  – even though I consult with health plans and health insurance companies daily and understand the claim process and the terminology, I still find the process challenging.

I have the misfortune to be part of the population least satisfied with our current health care system, individuals with chronic health conditions that require frequent medical care.  For this group, our lives depend the most on the system working.  Each medical service requires me to sort through multiple pieces of paper in an attempt to understand what was paid on my benefit claim, why that particular amount was paid and how much of the remainder is my responsibility versus amounts the service provider is expected to contractually write off.  Because my medical providers seem to be equally confused, I am frequently billed for things my health plan says is not my responsibility. For example, correcting the claim payment, correcting the bill and finally paying my medical bills often seems to be an exercise in frustration and futility.

Medical providers, especially many public and community not-for-profit hospitals are closing or struggling to survive. Many of the health plans, for which I consult, are operating on paper thin margins. Grocery stores have higher profit margins as a percent of revenue than some of my clients. Employers are struggling to maintain benefit plans for their employees in the face of double digit annual increases in their costs.

As Mange points out in his SOA essay, the incentives of the current health system are rewarding bad behavior:

• Because the benefits are paid by a third party for most of us, we as consumers have little incentive to control costs and very little access to information that would help us understand in advance the cost of the services and whether the services are really necessary or even in our best interest. The book Overtreated by  Shannon Brownlee provides a chilling perspective on the impact of excessive medical care on our health and well being.
• Because reimbursements to providers are based on the services provided, medical care providers have an incentive to prescribe more rather than fewer procedures for their patients.
• Health plan administrator’s costs are high because for each claim they receive, even the smallest ones, they must answer a series of difficult questions: is this patient covered by our plan, are these services covered by the plan, were these services medically necessary and appropriate for the individual, were the charges reasonable.

So where do we go from here? Mange’s essay highlights some steps I believe are key in moving forward.

• Educate policymakers and the public that medical insurance should be like other insurance, frequently bought and rarely used.
• Effect legal and regulatory changes that differentiate between prepaid medical care (i.e. payment for routine annual doctor’s visits and medical tests) and medical insurance.
• Require that costs be transparent.
• Require that insurance reimbursements be based on outcomes, adjusted as appropriate for complications.
• Encourage, but do not mandate the purchase of prepaid medical care.

It is with much pride and great pleasure that I write today’s post–Disruptive Women held its launch event at the National Press Club in Washington DC one year ago.

I am very proud to share that our blog has been named one of the Top 100 Health Care Blogs and has been nominated by readers of the Huffington Post as one of the 100 People Who are Using New Media to Change the World.

Today, I am pleased to say that our network consists of 40 incredible, very diverse, Disruptive Women bloggers, including our 4 newest:

• Diana Long, Developer of BrandDance TM & Principle, DML Consulting
• Diane Jones, President, Camden Counsulting
• Lisa Korin, Masters of Public Health Candidate, Johns Hopkins University Bloomberg School of Public Health
• Stephanie Cohen, Co-Founder, Golden & Cohen

In addition, we have our own You Tube Channel, Facebook Fan Page with hundreds of fans, thousands of Twitter followers and have hosted several briefings and events and published an e-book on Comparative Effectiveness Research.

As we look ahead to the coming year, we have many interesting briefings in the works, new e-books underway, and more Men of the Month who will be contributing.

We welcome your feedback and input, suggestions and ideas as we continue to disrupt health care.

Big news: The FDA is holding a public hearing to discuss online promotion of FDA-regulated medical products – including prescription drugs, prescription biologics, and medical devices. The hearing will be November 12 and 13, 2009 in Washington, DC (registration closes October 9 – see also registration instructions from Eye on FDA), but public comments can be submitted in writing or electronically now through February 28, 2010. View the docket details and full Federal Register notice.

A common reaction around the Web has been “Finally!” – with remarks like “This is NOT a Hoax!” and “Just in time for Web 3.0,” the FDA has set a date to start figuring out “how to deal with Web 2.0.” (NPR Health Blog).

But after the initial shock and sarcasm subsides, the potential significance of the FDA’s (albeit long overdue) move forward this week starts to sink in – this could result in the most significant set of regulations since the FDA’s guidelines for broadcast direct-to-consumer (DTC) advertising in the late 1990s. We’re talking industry-changing stuff here – or rather, industries-changing, because you can be sure that pharmaceutical companies, physicians, consumers, Internet and social media companies, the advertising and public relations industries, and everyone whose revenue includes online advertising are all major stakeholders in this public policy debate.

So what has the FDA highlighted as the key elements for discussion of this issue? (List below drawn from the 9/21/2009 FR notice)

1. For what online communications are manufacturers, packers, or distributors accountable?
   • (paraphrased) What communications and discussions should be considered “by, or on behalf of” versus independent of influence from these companies – and when and how should companies “disclose their involvementor influence,” particularly “on third-party sites”? Should different types of online media platforms and different intended audiences of these platforms be considered differently when addressing these questions – if so, how?
2. How can manufacturers, packers, or distributors fulfill regulatory requirements… in their Internet and social media promotion, particularly when using tools that are associated with space limitations and tools that allow for real-time communications (e.g., microblogs, mobile technology)?
   • (paraphrased) How should product information be presented on these platforms so that users have appropriate access to both risks and benefits?
3. What parameters should apply to the posting of corrective information on Web sites controlled by third parties?
4. When is the use of links appropriate?
   • (paraphrased) Should there be rules about the use of “links to and from Web sites,” including links to or from unbranded websites to or from clearly branded company websites? And what research and data exists about the click-rates in different contexts of users seeking information about medical products?
5. Questions specific to Internet adverse event reporting
   • (paraphrased) How are companies that are obliged to report adverse effects of products using online media tools, if at all, to monitor information about adverse effects of their products? Should these companies be obliged to monitor and/or report information from online communications concerning adverse effects of their products?

We – and the FDA – want to know what you think. What are your gut reactions to all of this – do you find anything particularly worrying, are there any potential outcomes you’re especially hoping for?

If you submit any comments to the FDA – and we hope you will – come by and tell us about it in our comment section here (and we promise to do the same). More information about the public hearing and submitting comments is available here.

Join three Disruptive Women on Wednesday, September 23rd, from 12-1 pm for a free webinar on open dialogues in health.

Wednesday, September 23, 2009 12:00pm – 1:00pm ET
Fostering Open Dialogues in Health: Disruptive Women in Health Care
Hot Topics in Genetics and Advocacy
Register for this event here: https://www2.gotomeeting.com/register/764236011.

Fostering open dialogues on hot topics in health presents unique challenges. Today, innovators are exploring the use of technology to generate multiple perspectives in these dialogues. The Disruptive Women in Health Care blog is an example of the rich and open dialogues happening online now. Hear about the model Disruptive Women in Health Care employed and their principles for fostering openness. Presenters will also outline health reform as an example of how this open dialogue is taking place and fostering interaction. Specifically, they will discuss ways care will be delivered from an integrated team-based approach, and how patients and caregivers will be active participants or advocates in the new health system created after health reform.

Presenters:

• Robin Strongin – President & CEO, Amplify Public Affairs, LLC; Creator & Founder, Disruptive Women in Health Care blog
• Ruthann Russo – Partner, Russo & Russo, LLP
• Pat Ford Roegner – CEO, American Academy of Nursing

Several months ago I was attending a funeral.  After being introduced to a relative’s relative, my family member asked me if I knew what had happened to Mr. Smith, pointing to the elderly man walking with a cane.  It was a miracle my family member said.  A miracle I wondered, looking skeptically at him.  Yes, Mr. Smith was having a CAT scan and the results showed that he had pancreatic cancer.  A miracle I asked, why so.   As it turned out the patient, who in his early 80′s went to his doctor complaining of not feeling well.  Abdominal pain. Distention.  General malaise and discomfort.  One thing led to another and CAT scans were ordered.   And as the family story goes, “by mistake” a CAT scan of his pancreas was performed.    And as I understand the story, the tumor was removed.  No metastasis was found.  The gentleman was advised to be sure to come in for his scheduled checkups and to tell his doctor about any subsequent health problems, and to be prepared for follow-up tests.   He was told that some tests will be repeated in order to see how well the treatment is working.  The recent death of actor Patrick Swayze reminds us that pancreatic cancer is so difficult to detect and diagnose early. There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer.  The signs of pancreatic cancer, are often like the signs of many other illnesses.[1]   Hmmm, I agreed, a miracle by accident.

We won’t ever be sure what could have been if we had paid more attention to the signs and symptoms. Mom had died in October 2006. Dad had visited her in the hospital and the rehab center and the nursing home for seven months, every day, day after day after day. They had been together for 50+ years. And he had been sure to tell the story of their meeting and their marriage and their lives together to anyone……. well actually to everyone that he met. After mom passed, he slowly managed to go on with his life without her. It was not easy. He had to learn how to use the microwave, how to make coffee, and how to cook. He mastered the art of grocery shopping and doing his own laundry. One day at a time we encouraged him. Slowly he managed to pick up the pieces and take care of himself. Or so we thought. Sure he often spoke of missing her. And he mentioned having trouble sleeping and not really feeling like eating. He told us that he often would get up in the middle of the night and then take naps during the day. He mentioned being invited to join friends for lunch or dinner but not feeling well enough to do so. He seemed more and more tired and uninterested in life. Dad we asked, did you go for a walk today? No, no, no he said, it’s too hot. Dad we said, perhaps you should see the doctor. No, no, no, I have an appointment next month. Dad we said, perhaps you could talk to the Rabbi. No, no, no, I don’t want to bother him. Dad, we said, your friends want to see you. No, no, no I am not good company. Dad, we said, please come visit ….. the grandkids want to see you. No, no, no…it’s just not that easy to travel at my age, he would say. Dad we said, why don’t we all take a vacation together? No, no, no he said, it’s just not easy to get around. Dad we said, why don’t you see a counselor or join a grievance support group? No, no, no, he said, I am just not ready. Dad, we agreed is really, really depressed about mom’s passing… his grief seems insurmountable. He’s really having a hard time being by himself. But even so maybe we should call his doctor…maybe it’s more than depression or grief. It looks like he’s losing weight and he’s always tired and seems to be sleeping more and more. The pain of his loss never seemed to subside. His grief seemed to appear mostly in physical ways: restlessness, exhaustion, sleeping problems, appetite changes, body aches, stiffness of joints, weight loss, and increased fatigue. But two years later he was still suffering much as he had back in 2006. Maybe it was time for us to insist that we go with him to his doctors.

Hmmm said the doctor…..weight loss, tiredness, loss of appetite, decreased energy, and depression. Let’s run some tests. Hmmm said the doctor lets get a scan. Hmmmm said the doctor I think we need an MRI. Hmmm said the doctor, I want to get a liver biopsy. Hmmm, said the doctor I am sorry but its pancreatic cancer and its spread to the liver and given your dad’s age and condition, I don’t think there is much we can do. Dad died in November 2008, two months after his diagnosis.

This month, Disruptive Women welcomes The Rev. J. Bennett Guess as our Man of the Month. Rev. Guess is a special choice for this honor, because he’s not specifically a member of the health care community. But as Director of Communications for the United Church of Christ, he is taking on health care reform as a moral issue with a push for action called 100,000 for Health Care.

On June 26, 2009, the Twenty-Seventh UCC General Synod passed a resolution calling for advocacy in support for Health Care For All. Some people may be wondering why this issue was so important to the UCC that a resolution was called for. Let me show you an excerpt from the Pastoral Letter to UCC members, to explain:

[The] familiar story of the Good Samaritan in Luke’s Gospel makes a clear case for universal access to health care. Jesus reminds us of what it means to love our neighbor; it means we stop and assist in a caring manner that nurtures the neighbor back to health and wholeness. Persons in need are not to be passed by, nor are they to be left abandoned and ignored by the side of the road. (Read the entire Pastoral Letter here.)

Our faith teaches us that health care is a both a human need and a human right. Offering comfort to the broken, sick and injured was foundational to Jesus’ ministry and is central to our serving the least among us. That’s why we are adament that our nation deserves a health care system that is inclusive, accessible, affordable and accountable. To us, health care is not a liberal or conservative issue… it’s a moral issue.

Just consider:

• Over 47 million people (one in six) and over 9 million children are without health coverage and 25 million more are under-insured.
• Every year, 18,000 people in the United States die from a lack of health insurance—that’s two people every hour.
• More than 60 percent of all bankruptcies are linked to medical expenses. About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs.

As members of the United Church of Christ—and as members of the human race—we think this is unacceptable. And we’re doing something about it.

Our campaign is called 100,000 for Health Care. Our hope is to send 100,000 email messages to Congress and also deliver this huge book of 100,000 names to the Democratic and Republican leadership in Congress. Together, speaking as people of faith, we know we have the power to change the conversation and envision a society where each person is afforded health, wholeness and human dignity.

Of course, you don’t have to be a UCC member or a member of the Christian faith (or any faith, for that matter) in order to help. If you agree that health care is a basic human right, then please sign our petition and spread the word. We’re counting on the force of 100,000 signatures as something that our leaders can’t ignore. Let’s be disruptive together!

As I check Facebook before going to Program Planning for Health Behavior Change class, I can’t help but look at this pre-class behavior of mine in terms of some of the concepts I am learning in the classroom. We can keep in touch with all of our friends quickly and efficiently with the click of a button and thanks to the Internet, but on the whole we aren’t quite as compulsive about getting the recommended nutrition, exercise or health services upon which our livelihoods depend.

Much blame has been put on individuals for not exercising, eating properly, or managing their chronic conditions, thus burdening the healthcare delivery system. Some ask, if we have tons of healthcare literature out there and people know what is the ‘right’ thing to do—eat 3-5 fruits and vegetables a day, exercise for 30 minutes most days of the week, etc.—why aren’t people more adamant about taking care of themselves?

Sure, people are accountable for their actions. But I ask, what is it about the environment we live in that makes it so easy to instill the habit of checking Facebook constantly, yet so difficult to inspire people to take care of themselves? Why aren’t venues that sell fresh fruit and vegetables as abundant as fast food restaurants? Why has the food industry been able to sell us larger portion sizes that provide a bargain for our pocketbooks but make us chronically sick? Why are we so reliant on automobiles and don’t live closer to where we work, shop, go to school, etc.? And since we don’t walk or bike everywhere, why are our lives so demanding that we don’t have time to make moderate exercise part of our daily routines?

(more…)

On Wednesday night, President Obama addressed a joint session of Congress on the topic of health care debate. Here on the Disruptive Women in Health Care blog, we’ve closely followed and covered the health reform process since the President’s election.

We know our readers are passionate about the future of health care in our country and so we’d like to hear your opinion!

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Do you ever wonder who the champion advocate for the patient is in the healthcare reform debate? More importantly, is the focus on consumer choice taking a front seat while the issue of how consumers will ultimately respond to those choices is being ignored?

Many people, myself included, believe that in aggregate, individuals are best equipped to advocate for themselves. In fact, this hypothesis forms the foundation for a key component of Health 2.0, in which the consumer takes more responsibility for managing his or her healthcare and by default, the delivery of that care becomes more fluid and cost-effective.

The rub, however, is that data suggest that most consumers of healthcare rarely if ever speak up.

A fascinating report published in the September issue of Milbank Quarterly shows that fewer than 40% of 5,000 patients surveyed complained to healthcare insurance plans when a problem arose, even when it cost them upwards of $1,000 in out of pocket expenses or if care (or lack thereof) led to a more serious health condition. What’s more, less than 15% of patients took steps to opt out of their current plans and search for a more palatable option.

What these results demonstrate is that current response to the coverage being delivered neither safeguards the patient or serves to highlight the most significant problems among current plans in the marketplace.

Clearly, two major components are missing in the current debate: unique, consumer-driven advocacy and optimized patient responsiveness. Without these, even the most attractive new options on the table may ultimately fail to lead to better overall quality of care.

We start this short Labor Day week on a hopeful note. The President will speak to the nation on health reform in just two days. Perhaps this is the tipping point we’ve been hoping for and it will break the logjams, bring all the players back to the table, keep them there and forge the next steps forward.

Recently, however, is unsettling debate about the value of prevention – saying it costs more and won’t help our health care crisis. Yes, prevention will cost more health dollars. Let’s get over it and move on – and beyond – that. I did on August 1, 2001, just six weeks before that fateful September 11 day.

I was the wrap-up speaker at a conference focusing on resistant pathogens and the problems that could ensue for the American hemisphere from emerging diseases. The audience as comprised of public health, medical and national security experts. The session was broadcast globally to 80 nations in three different languages. I opened with these remarks;

“We began this session stating that our goal was better health outcomes. I would like to propose a bigger goal: world peace and prosperity—for everyone, not just in this hemisphere, but throughout the entire globe.

Peace and prosperity will not be possible if we fear our neighbors for the pathogens they may harbor in a handshake. These will not be possible if we spend our money treating diseases that we could have prevented. These will not be possible if we are burying our loved ones precisely at the time when they are the most economically productive, or, when they are very young or very old and not enriching our economies, but enriching our hearts.”

The reaction was stunning. People cried. Afterwards, when the telecast was done and I came off stage I saw what it might be like to be a rock star. I was surrounded. They came to touch me and to tell me how I had touched them. It was then that I realized how weary we all are of working our best to shave another cent from the health care dollar and how much we all wanted a higher purpose for our work.

Regardless of what transpires in health reform debates, I hope that policy makers will realize that health – though valuable in-and-of itself – is an instrument of bigger goals.

I hope they will not set their sights too low and act as if it’s all-and-only about cutting costs. I hope they will see that a healthy population is a productive one and in this economy that’s exactly what we need: people who are capable of managing the stresses of these modern times, who can work more productively and work longer to bring this nation – and the world – forward to its full potential of peace and prosperity for all.

With Labor Day a few hours away, a turbulent summer draws to a close.  But Democracy is a messy thing and rather than dwell on the gross distortions and histrionics we sweated through this past August, I prefer to focus on the chance to get health reform back on track. Now that’s something to sing about.

That is, moving from the THEME SONG FROM MISSION IMPOSSIBLE to WE SHALL OVERCOME.

I started thinking about how various songs could represent different aspects of health reform.  And once I started thinking about music, Elvis immediately came to mind.

I just happened to have a copy of Elvis Presley’s Commerative Issue: The Number One Hits nearby when writing this post.  Almost every one of them could be related to health reform.  In addition to Elvis, a few other songs seemed to have something to say about health care.

Here then, is my playlist:

I WANT YOU, I NEED YOU, I LOVE YOU–What Obama should be singing to the Blue Dogs

HARD HEADED WOMAN–This one’s for Senator Olympia Snowe–a true Disruptive Woman–keep up the good work.

IT’S NOW OR NEVER–Congress, are you listening?

ALL SHOOK UP–The state of the American public after all the town halls this recess

HEARTBREAK HOTEL–What the White House will become if health reform ends up DOA

SURRENDER–Not an option

TOO MUCH–Bend that cost curve, stat

SUSPICIOUS MINDS–a condition that runs along K street

DON’T BE CRUEL–Message to those in elected office who think things are fine just the way they are

ARE YOU LONESOME TONIGHT–This one’s for all the staffers who haven’t been home in months

JAILHOUSE ROCK–Congress, jail…enough said

TEDDY BEAR–No discussion (or song) about health reform is complete without the mention of Senator Ted Kennedy, may he rest in peace

In addition to Elvis, there are so many other artists who, whether they knew it or not, have been singing about health policy issues:

H1N1

ROCKIN’ PNEUMONIA & THE BOOGIE WOOGIE FLU (Johnny Rivers)

FEVER (Peggy Lee)

Aging

FOREVER YOUNG (Bob Dylan)

YOU MAKE ME FEEL SO YOUNG (Frank Sinatra; Ella Fitzgerald)

Politics–Senator Grassley’s Theme Song

THE GREAT PRETENDER (The Platters)

As an insurance broker in the metro Washington DC area, I have been in the trenches of selling, and advocating for our customers for their small group health insurance, disability programs and life insurance plans for over 17 years.

Needless to say, it has been maddening in the last five years to watch rates rise and our customers get increasingly frustrated with the system. I spend my days arguing with insurance companies about what they will cover and what they won’t — and I’m consistently amazed that these large firms often don’t have a handle on the benefits they provide in their policies. To say the right hand doesn’t know what the left is doing is a dramatic understatement.

I am one of the first to admit that something needs to be done. Last fall I hosted the DC Health Summit and brought together some of the country’s top health insurance executives, doctors, politicians, hospital administrators and business people into one room to discuss what might be done to fix the system.

An Obama spokesperson was one of our speakers — and today I continue to stand behind the president’s goal to accomplish health care reform, and do it as soon as possible.

As the debate has unfolded, however, it has been suggested that health insurance brokers be eliminated from the mix. Obviously, this potential threat is unnerving, but if you consider the possibility on a more global level — it simply doesn’t make sense.

Here’s why: If we have a government option in health care reform, over a short period of time, it will likely crowd out the private sector. If private health plans are squeezed out of the market, it follows that insurance agents will be as well, and that would be a major loss — not just for my firm, but also for every American who currently relies on their broker to explain their benefits and advocate for them when there is a problem.

I believe it is critical that the broker not be categorized as an administrative cost — especially as those costs are the biggest target in the reform packages. We also want to make sure Congress doesn’t do anything that removes us from the system, or removes the value that we know we add for the customer.

So let’s consider the doomsday scenario for brokers.

If the current threat comes to fruition and brokers like myself are put out of business, I’m certain there will be a consumer advocate of some sort under any new model that is adopted. Like with many government-run programs, will these be poorly trained people be truly knowledgeable about how the system works? Will they be advocates for their customers? Will they have the time, resources, or incentive to spend five hours on the phone in a day — as I often do — arguing for a patient’s health insurance rights?

Not likely. Indeed, odds are good that we’ll end up with internet-based FAQ pages filled with complex explanations. I can foresee the day when trying to understand your health insurance benefits will resemble trying to understand how to do your taxes. Will we look back on these days as the good times for our health insurance benefits?

Needless to say, I believe strongly that brokers are an important part of the health care system. I hope to have the privilege to continue to do my job for many years to come.

More than 100 opinion leaders from all over the globe (including several Disruptive Women) participated in the Aspen Health Forum last month to discuss the most pressing health issues facing the nation and world. President Obama’s health care reform agenda, the emergence of swine flu, HIT, food safety and strategies for defeating the obesity epidemic were among the many issues discussed.

Watch Nobel laureates, federal decision-makers and world-class medical scientists impart their insights here: http://www.aspenhealthforum.org/video.