The Disruptive Women in Health Care blog continually aims to encourage discussion and debate among readers about emerging issues and topics in the health care world. Historically, one of the ways that we have done that is through our weekly round-ups – that is, posts containing summaries and links to some of the big stories in health care news for the given week, with some original commentary and content sprinkled in as well. The way we see it, there is just too much happening in this burgeoning industry; it’s hard to keep up, especially when you’re busy disrupting and making headlines in the health care world yourselves. We know the weekly round-ups have been on hiatus for a while, but are happy to report that they’re finally making a comeback. Each week, we’ll be gathering some of the biggest health care news you can use from at home and abroad for posting on Wednesdays. Feel free to comment on what’s included and send us some links to articles to be considered for next week!

Has your week been too disruptive for you to keep up with the news?  Disruptive Women are on the case!  Here is this week’s round up of some of the most pressing issues here in America and around the world.

Here at Home:

Thanks to a provision of the Affordable Care Act (ACA), women are now able to receive free birth control, but only if it’s prescribed.  The New York Times explains how Catholic Colleges are using this loophole to combat contraception.

And, speaking of the Catholic Church and the ACA, USA Today says that Obama’s decision on Friday not to expand the conscience exemption to include religious institutions has been met with outrage from Church leaders and parishioners.

Remember that moment of panic you had when the swine flu epidemic came to the United States?  CBS News reports that swine flu numbers are rising again in Mexico. Will the US be next?

Susan G. Komen for the Cure, the nation’s leading breast cancer charity, announced Tuesday that it is halting its partnership with Planned Parenthood (per NPR) – a controversial decision that ignited a backlash from some of its supporters.

Here’s one perspective on Komen’s decision. What do you think? Will this impact your decision in giving donating to Komen, or another breast cancer non-profit in the future?

Sick? Took a sick day?  Is that enough of a reason for you to wind up unemployed?  HuffPo explains how an issue as simple as recovery from the flu has reached the Supreme Court.

With nearly two million women lacking health insurance and a quarter of a million unplanned pregnancies per year, Florida has a lot of challenges in terms of women’s healthcare.  Here’s what the state is doing to try and move ahead.

Around the World:

Brazil is calling for a registration of all pregnant women.  What does this mean for a woman’s right to choose within Brazil?

Japan’s population is shrinking. As more women choose a career over family, Japan faces declining birth rates. Could the United States be next?  ABC News takes a look.

Check back each week for the latest health care news!

There is, however, one area we don’t touch (in fact, we avoid it at all costs): partisan support for a candidate. While certainly all of our individual bloggers have opinions and perspectives, points of view and inherent biases, we will never run posts that are blatantly promoting one candidate for elected office over another.

I say this as a caveat to this post, the purpose of which is to announce a new series we’ll be running this year on the Disruptive Women in Health Care blog in which we explore the presidential candidates’ positions on health care and health policy, where they stand on particular aspect or aspects, what they envision to be an ideal health care system for this country and what role they envision the federal government playing in it.

This series is about more than just the Sustainable Growth Rate (SGR), the Affordable Care Act (ACA) or Medicare and Medicaid; it is about delving into each candidate’s philosophies, beliefs and stances towards health care and health policy, and trying to determine what specific policies and reforms each might undertake.

Image courtesy of the Mobile Press-Register.

The editorial team and I are very excited to be launching this series, as we feel it will provide us the opportunity to address important issues during a significant year from a much different perspective and in much greater detail than the mainstream media is likely to discuss.

You can expect to see a lot of substantive political and policy analysis being put forth via the series in the coming weeks and months, but like I said earlier — one thing you definitely won’t see is bias towards one particular candidate (though our posts will certainly contain links to articles from other outlets that may or may not be biased, because we feel it is important to provide a survey of what others are saying on the topic). Help us make the series even better by letting us know what topics or specific policy areas you would like to see explored – we’ll do our best to incorporate your feedback into upcoming installments.

We’ll be back with our first full installment of the series in the next few weeks, but in the meantime, we’ve rounded up some related articles we think are worth reading:

• CNN takes a look at claims of Medicare fraud being made against Mitt Romney by a pro-Newt Gingrich super PAC
• NPR explores “Romney’s unlikely and persuasive defense of the ‘Individual Mandate’”
• WaPo discusses Rick Santorum’s position on abortion in the context of his personal experiences

CMS Administrator Marilyn Tavenner addressing Care Innovations Summit attendees. Image courtesy of Kaiser Health News.

“I think we would all agree that these are not ordinary times, that this is not an ordinary conference, nor is it an ordinary time in health care,” commented Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner, in her address at the first ever Care Innovations Summit Thursday. In saying so, Tavenner captured not only the essence of the problems facing our nation’s health care system and the reason that over a thousand national thought leaders, senior government officials and industry experts had gathered, but also inspiring attendees with the idea that, by being there, they had the opportunity to be a part of the solution.

Driving the day at the Care Innovations Summit, which was hosted by the Center for Medicare and Medicaid Innovation (CMMI), Health Affairs and the West Wireless Health Institute, was the notion that American innovation could solve any problem, and the thousand-plus attendees were the innovators to solve this one. Emphasizing CMMI’s founding mission of better health, better care and lower costs, speakers across sectors, industries and areas of expertise continued to echo each other’s cries that it was all possible, if people began collaborating and innovating across fields.

Even before HHS Chief Technology Officer Todd Park compared data to rocket fuel, the Summit was beginning to sound like President Kennedy’s speech to Congress announcing the Space Race. In fact, the addresses and panels were broken up by “Ignite Talks” — wherein private-sector stakeholders presented problems and issued challenges to attendees and to entrepreneurs across the country, offering not only prizes, but implementation funding for the best solutions (you can see a list with links to descriptions of the various challenges issued here).

Park best captured the sentiment of the Summit, saying, “There is no problem that Americans can’t invent themselves out of…Transformation driven by a tide of grassroots innovation mojo has already begun.”

While this sentiment and attitude towards repairing and revitalizing our nation’s health care system certainly drove the day, it is not new, nor is it exclusive to CMMI. In fact, it echoes many of the themes that motivated us to launch the Health in Place™ (HIP) initiative last month. The concept of HIP is built around the idea that, thanks to wireless communications and emerging technologies, our homes are more than ju

st houses, our offices are more than just workplaces, our schools are more than just places of learning and our cars are more than just modes of transportation — and that, for this facet of 21st century health care to achieve its full potential, a number of public policy issues are involved, cutting across multiple disciplines from health care regulations and benefit structures to tax policy and technology incentives. HIP aims to connect the dots between industries, inspire innovation and drive policy changes that accomplish CMMI’s goals of better health, better care and lower costs while simplifying things in the process.

With all of this collaboration and innovative thinking, there is no doubt that this is an exciting time in health care, but as Don Casey expressed in his closing remarks at the Summit, there are some significant obstacles to overcome to get the rockets to the moon. “I think a lot of people are skeptical about two things,” Casey said, “the American economy and do we have the ingenuity to get this stuff done, and can we actually engineer a jailbreak for health care.”

Are you planning to take part in any of the innovation challenges issued? Do you think cross-industry collaboration is really possible? And, what do you think we need to do in order to break down the barriers Casey and others at the Summit alluded to?

If you chose to partake in what HuffPo referred to yesterday as “ your country’s empty displays of patriotic kitsch” — aka a State of the Union Drinking Game — last night, I certainly hope health care wasn’t one of your buzzwords.

President Obama delivered his 4^th State of the Union (SOTU) address to Congress last night, outlining his goals and his priorities for the nation in the coming year, and – as Sarah Kliff from the Washington Post’s WonkBlog put it  – “For health policy wonks, Tuesday night’s State of the Union speech wasn’t a thriller.”

In fact, in his nearly 70-minute, 7,000 word address, “President Obama mentioned Medicare and Medicaid… once. ‘Health care’ got two shout-outs. The Affordable Care Act? Not even a name-check,” (per Kliff).

To think of it another way, consider how Daily Briefing editor Dan Diamond broke it down — the president spent 44 words on health reform, accounting for 0.6% of the total speech.

As Politico pointed out, “Obama spent so little time on the [health reform] law that he didn’t even acknowledge an audience member the White House had brought to the speech — a cancer survivor who could have been an example of someone with a pre-existing condition who was helped by the law.”

The White House had announced earlier Tuesday that this young man, Adam Rapp, would be sitting in the first lady’s box. Rapp was diagnosed with testicular cancer on his 23^rd birthday, the same day that he would have lost health insurance coverage were it not for the Affordable Care Act (per CBS) – a potentially powerful testament touting the impact of ACA, and yet one that went unmentioned.

All of this is more staggering when you consider what a departure it represents from years past.

Medscape Medical News reports that, “Obama mentioned either “healthcare” or “health insurance” only 3 times, compared to 6 references in 2011 and 10 in 2010.”

The California Healthline blog lays it out a bit differently, explaining that, “Two years ago, the president spoke for several minutes — a total of 570 words — in urging Congress to pass the Affordable Care Act. Last night, Obama devoted just 44 words to his health reforms — never once touting the law’s actual impact, like 2.5 million young Americans gaining coverage through the ACA. In comparison, the president spent more than 130 words on his renewed cause of streamlining the government.”

And for you visual learners and/or infographics enthusiasts like myself out there, Dan Diamond tweeted this graphic a few hours ago, which I think best serves to drive the point home.

Wondering what Obama spent 70 commercial-free minutes talking about, then? According to the Washington Post, the economy mostly. Check out WaPo’s interactive infographic breaking down the speech by time spent/mentions per subject, and how this year’s spread compares to his previous SOTUs, here.

Meanwhile, the GOP rebuttal, delivered by Indiana Gov. Mitch Daniels, was only marginally better to us health wonks – at least for our interest’s sake. While it steered clear of “repeal and replace,” it did echo Rep. Paul Ryan’s pitch for an overhaul of entitlement programs.

“Medicare and Social Security have served us well, and that must continue. But after half and three-quarters of a century respectively, it’s not surprising that they need some repairs,” Daniels said. “We can preserve them unchanged and untouched for those now in or near retirement, but we must fashion a new, affordable safety net so future Americans are protected, too.”

No one would deny that the SOTU, above all, is an act of political theater. But were there even more theatrics occurring last night than usual? Many Beltway insiders have seemed to indicate this, saying that the SOTU was not only a list of goals for the year, but also, as Kliff put it, “an opening campaign gambit.”

If that is the case, it raises some interesting questions about what we can expect to hear in the fall. After all, as The Hill’s Healthwatch blog pointed out, “Although Democrats insist that Obama will be able to campaign on the healthcare law, it was almost entirely absent from a speech that helped establish the themes and frames of his reelection campaign.”

Just because the president seems to be steering the narrative away from health care so far doesn’t mean it won’t be issue in the upcoming presidential election. Odds are that the Republican nominee – whoever it turns out he (or she… hey, you never know!) may be – will want to discuss health reform, as it has certainly been a hot topic on the campaign trail.

How important of an issue do you think health reform will be in the upcoming election? Will a candidate’s position on health reform and the Affordable Care Act impact your decision to support him or her? Tell us your thoughts in the Comments section below!

Millions of Americans disapprove of the Affordable Care Act without understanding what the act aims to accomplish or how it works.  Dr. Jonathan Gruber’s book “Health Care Reform:  What It Is, Why It’s Necessary, How It Works” breaks down the individual components of the act in order to give Americans a greater understanding of what all it includes and how its provisions will affect their daily lives.  Gruber discussed the book, ACA and the future of health care reform in the United States with an audience at Disruptive Women in Washington, DC last night.

Continue reading here…

In the study, J.D. Power segments brick-and-mortar pharmacies from mail-order. Brick-and-mortar pharmacies cover chain drug stores, supermarkets and mass merchandisers/Big Box stores.

What drives top performance for consumers shopping brick-and-mortar pharmacies are the ordering and pick-up process, the store itself, cost, the non-pharmacist staff, and the pharmacist.

In mail-order, quality translates into cost competitiveness, prescription delivery, ordering, and customer service. Consumer satisfaction with the mail-order Rx channel declined between 2010 and 2011, primarily due to ordering and delivery problems. But due to price and challenges in switching back to the brick/mortar option, mail-order customers are largely expectedly to remain in the channel and not switch to a store. One-third of consumers are required by their insurance provider to use mail-order for maintenance and repeat scripts – these customers are even less satisfied with their pharmacy than those who freely choose to go the mail-order route for prescriptions.

J.D. Power, analysts on consumer satisfaction, notes that Amazon has set a high bar for speed and convenience in the online shopping world. Mail-order pharmacy has a ways to go to catch up to those standards.

High customer satisfaction ties to those consumers who have an ability to have a private conversation with the pharmacist or staff in a private area of the pharmacy. Furthermore, added services such as immunizations and wellness services are driving higher consumer satisfaction with those pharmacies who offer them.

The highest rankings by segment were:

Chain drug stores: Good Neighbor Pharmacy, Health Mart, The Medicine Shoppe (all well above competitors in the segment)

Mass merchandisers: Target, Sam’s Club, Costco (with Walmart at the bottom)

Supermarkets: Publix, Wegmans, Winn-Dixie, Jewel-Osco, Vons (all above the segment average)

Mail-order: Kaiser Permanente Pharmacy, Humana RightSourceRx (both well above competitors).

This is the fifth year J.D. Power has conducted the national pharmacy survey. The poll, fielded in May and June 2011, was conducted among 12,300 consumers who filled a new prescription or a refill in early 2011.

Health Populi’s Hot Points: The pharmacy has always been a touchpoint in consumers’ health, but its importance is growing as a primary care site for wellness, prevention, immunization and a growing menu of consumer-driven primary health care services. The supermarket channel, in particular, has begun to marry messages about nutrition and healthy food with chronic health condition messaging. For example, Wegmans (ranked #2 after Publix stores, features a food/health related display adjacent to the pharmacy: this month, my local Wegmans has been promoting quinoa’s nutritional contributions to healthy eating at a “pharmacy teaching table.’ In the winter, the pharmacy promoted the purchase of frozen blueberries to enhance shoppers’ intake of the fruit’s health benefits in the cold season.

This is another example of health being where our Surgeon General says it is – not in isolation in the doctor’s office, but where we live, work, play and pray. Let’s add the word “shop” to that mantra.

On a personal note, I have a comment to make on J.D. Power’s mail-order pharmacy results. In the past six months, we have been forced to switch to the mail-order channel to acquire a repeat prescription for a member of our family. The company, whom I will not name, is one of the poorer performers on the table – and no surprise to me. The company has a cumbersome, un-helpful, poorly designed website which it claims streamlines the process. For the first three months of the fulfillment process, I’ve had to dial into the company’s call center – which has no hours on the weekend, when I, and most working people, usually run household errands. Suffice it to say, after speaking with the doctor-prescriber’s insurance associate, our experience with this mail-order company was not atypical.

Would that this company, whose services I am compelled to use, could demonstrate the efficiency, accessibility, and friendly quality of my favorite shoe purveyor – Zappos. This is a case where I cannot, if you’ll excuse the pun, vote with my feet.

This weekend, I was among those following the cable news shows to see if Congress would finally reach agreement on a debt ceiling package.  It appears now that, even though it may be a “sugar-coated Satan sandwich” to some, a legislative approach has been crafted that will raise the debt ceiling and establish a process for achieving approximately $2.5 trillion in budget cuts over 10 years. 

In this process, a congressional super-committee will be charged with identifying $1.5 trillion in deficit reductions by Thanksgiving.  If they fail to do so, automatic cuts will occur and fall most heavily on the defense budget and Medicare.

As I was watching the news analysis, though, I saw a continued misunderstanding of what it means to cut Medicare provider payments.  One commentator praised the deal for protecting the most vulnerable in society, pointing out that Social Security and Medicaid were exempt from cuts, and Medicare cuts “would only affect providers.’  We’ve seen the same type of analysis several times today in print reports.

This kind of verbage creates the impression that an acceptable way to reduce Medicare spending, in a way that doesn’t do harm to patients, is to ratchet down payments for physicians, hospitals, medical devices, pharmaceuticals and medical supplies.

What is seldom acknowledged is that, for every percentage point shaved off of Medicare provider payments, seniors lose a little more access to quality healthcare.  We’ve already learned, thanks to a survey by the American Medical Association, that approximately one in every three primary care physicians is limiting the number of Medicare patients in their practice.  That’s the consequence of payment levels that are significantly below private insurance levels.  Given the rising number of baby boomers entering the Medicare program, the last policy change we need is one that will reduce the number of physicians available for this population.

That’s the consequence, though, of budget reductions that “only affect providers.”

Originally posted on Prognosis Blog on August 1st.

9 million. That’s how many web hits are returned during a Google search for “Accountable Care Organization,” and reflects the countless articles, white papers and opinions that have been published regarding the potential successes and more likely pitfalls of the proposed ACO mandate. As highlighted in TripleTree’s recent post, our team is continuously evaluating the business development opportunities being fueled by the demands and requirements of these new provider organizations.  Last week, the members of our Healthcare Executive Roundtable recently discussed and debated an element of the ACO equation that is not typically highlighted but is clearly a critical component of ACO success (or failure)…Trust.

In boardrooms around the country, health care executives are focusing on the technical requirements for their future ACO’s clinical and administrative systems. They are pouring over spreadsheets and attempting to understand the data and analytical tools that will be necessary for adequate financial and quality of care reporting. Getting these operational elements “right” is important; however, these business leaders should also focus on designing a culture – and the corresponding behaviors, communication, and incentives that will fuel strong and collaborative relationships between the ACO and its community of providers.

As Ed Brown, CEO of Iowa Clinic puts it, “People are unclear about what the value-based world looks like, and they’re unsettled on what clini­cal integration really means. And nobody has really made it work.”  This lack of clarity around the value-based model will make it challenging for providers to leave the financial security blanket of the traditional fee-for-service payment engine.  Moreover, influencing them to modify their approach to patient care for the benefit of the system and the promise of shared savings is a monumental effort. Success by any measure will largely depend on the trust established between providers and the ACO organization itself. ACO’s should prioritize establishing trust with providers in three key areas:

• ACO Operations and Management:  Providers need to trust that the ACO is well run. Understanding the organizational governance, expertise of the management team and core capabilities (strategic assets) will help generate confidence that the ACO is well-positioned to generate enough shared savings to make participation worthwhile. In addition, it is critical that the ACO measure and report management performance metrics that demonstrate its accountability to the providers.
• Compensation Incentives:  Providers need to trust that they are getting their fair distribution of shared savings. Clinical algorithms defining quality and outcomes must be evidence-based; and the financial tools and risk-adjustment methodologies used to distribute payment must be easy to understand. Above all, the organization’s compensation schemes must be highly transparent and accessible so that providers can validate that they are being treated as an equally valued business partner in the organization.
• Confidence in Provider Team:  Providers need to trust their ACO provider colleagues. If the right incentives are in place to bring members within the organization together, providers will need to trust that their peers will also be active participants working toward fully coordinated care within the ACO. Under an accountabilities and outcomes-based model, it will be important that providers view their care responsibilities as extending beyond the encounter. Active provider participants should be practicing first-class follow-up care, improving patient satisfaction, and reducing re-admission rates which will achieve collective rewards.

The inclusion of ACOs as a provision of the Patient Protection and Affordability Act is a strategy to realign delivery systems in the US so that they provide high quality, coordinated care.  The bottom line for achievement might simply boil down to whether providers can engage in meaningful and integrated relationships with the ACO and with each other. Since relationships are based on trust—predictability, integrity, and reciprocity–it is imperative that ACOs make trust a deliberate priority.

• About half (51%) of Americans who like the law cite expanded access to insurance and health care as the reason. Those who do not like it give a greater variety reasons: 20 percent are concerned about costs; 19 percent have concerns about government’s role; and 18 percent mention opposition to the individual mandate.

• A majority of Americans do agree on something: 53 percent are confused about the law, the major provisions of which won’t take effect until 2014. This is nearly identical to the 55 percent who reported being confused in April 2010. Further, 52 percent this month say they do not have enough information about health reform to understand how it will impact them personally, while 47 percent think they do. Members of the groups most likely to benefit from health reform — the uninsured and those living in low-income households — are the most likely to say they do not know enough about the law’s potential impacts.

• With Republicans quite critical of the law and some state officials chafing at its requirements, the issue of how much flexibility states should be granted, and with what conditions attached, has been a subject of debate in Washington. Two-thirds of Americans agree that states should be able to substitute their own health reform plans provided that they are as comprehensive and affordable as the national one created by the new law. The idea wins majority support across the political spectrum, backed by 75 percent of Republicans, 72 percent of independents and 55 percent of Democrats. But public support for state flexibility drops sharply if people think states would use substitute plans to save money by offering more limited insurance to fewer people than the national plan would. In that case, roughly two in three Americans (65%) would oppose state substitution, while 26 percent would still favor it.

• The requirement that nearly every American obtain health insurance – known as the individual mandate – remains unpopular, with 67 percent of the public supporting the repeal of that provision. That view is not an immovable one, however. For instance, support for repealing the mandate fell to 35 percent when those who initially supported repeal were told that “under the reform law, most Americans would still get coverage through their employers and so would automatically satisfy the requirement without having to buy any new insurance.” There was a similar, if smaller, drop in support for the mandate’s repeal to 48 percent when repeal supporters were told that without such a requirement people might wait until they were sick to buy insurance.

• At the one year mark, seniors continue to be more skeptical about health reform than other Americans, with 52 percent holding an unfavorable view of the law in March and 40 percent holding a favorable one. This month, however, saw a break in the trend of increasing negativity among seniors toward health reform that began in December. Unfavorable views of the law among seniors dropped by 7 percentage points from February to March, while favorable views increased by 8 percentage points. Still, by a two-to-one margin, seniors are more likely to believe that Medicare will be worse off (39%) than better off (19%) because of health reform.

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation. The survey was conducted March 8 – 13, 2011, among a nationally representative random sample of 1,202 adults ages 18 and older. Telephone interviews conducted by landline (801) and cell phone (401, including 171 who had no landline telephone) were carried out in English and Spanish by Princeton Survey Research Associates. The margin of sampling error is plus or minus 3 percentage points. For results based on other subgroups, the margin of sampling error may be higher.

A complete report, chartpack and the full question wording and methodology of the poll can be viewed online.

The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues.

I wondered about that as I saw some disparate bits of data over the weekend. An article on Valentine’s Day spending was informative: couples will spend just under $70 on each other and we’ll spend, on average, $5 on pets, $6 on friends, $5 on teachers and $3.50 on co-workers.

What will we be buying? In all, about $12.B in treats for the day: $3.5B on jewelry, $1.6B on clothing, $3.4B on dinner, $1.7B on flowers, $1.5B on candy (of which $285M will be on chocolate) and $1.1B on greeting cards.

I get interested in items like this when I hear that we ‘can’t afford health care.’ I’ve noticed over the years how we can spend more on the launch of a blockbuster movie in a weekend than we spend immunizing our children against measles, mumps and rubella in a year. 

In the past, I might have gone on a rant about that but this weekend another set of statistics caught my eye as well; those related to chocolate. Seems that chocolate-making companies have higher margins than other food companies, raking in 11.7% profits over the 8.1% of others.

Chocolate is a discretionary, luxury item and – though some friends will disagree – not at all essential to a person’s health or well-being, so we need not quibble over those margins, argue for price controls or suggest the industry become a public utility. That same article cited per-capita rates of chocolate consumption, however, which got me to thinking that consumption of chocolate appears to be correlated with two items we care about in health care: expenditures and satisfaction.

Sure enough! Though not a perfect correlation, it’s directionally so. Countries with higher rates of chocolate consumption have lower rates of dissatisfaction with health care and lower per capita health care spending. Wow!  Note in particular the difference between Switzerland and the US. The Swiss eat twice as much chocolate, have a dramatically lower percentage of people who grouse about healthcare and spend nearly half per capita as Americans. 

The policy wonk in me says perhaps we ought to make chocolate a covered benefit and promote its use! And, I’m only half kidding.

The first of those facts – being female – is the biggest dinger of the three when it comes to health insurance premiums. The reasoning there: women use more health services, starting in their teens and 20s and continuing through menopause. The second – my age – could signal a better rate, since women typically tail off in their use of healthcare in their mid-50s. However, the third fact – cancer within the last 10 years – gets me insurance coverage quotes of $2,000 per month, with a deductible between at $3,000 to $6,000 a year.

For the math-challenged, that’s between $27,000 and $30,000 out of my pocket per year before insurance covers Dollar One. Since that amounts to much of my annual pre-tax income in each of the two years since Cancer Year – 2008 was the last year I had health insurance coverage – I’ve remained on the uninsured list. And developed some fierce opinions about the future of healthcare and health insurance in the US.

The Patient Protection and Affordable Care Act, a/k/a “health care reform,” passed earlier this year includes some help for my situation…in 2014. Meanwhile, I’m managing to get the oral chemo meds I’ll be taking until 2013 (which cost $500 a month) with the help of a community clinic. And I’m keeping my fingers crossed that I stay as healthy as I was before the cancer diagnosis, and as I have been since I finished radiation treatment in 2008.

That’s my current health insurance policy: crossed fingers.

There are two things that I think have to happen to bring about meaningful change in the healthcare cost/payment/insurance conundrum, for me and everyone else:

1. Tort reform
2. Severing health insurance from employment

I realize that the tort bar, the health insurance industry, and pretty much everybody with a job-related health benefits package will take out a hit on me for making those suggestions. But the system has fallen, it can’t get up, and until major changes – not the chipping-away-at-the-edges approach of the current iteration of “health care reform” – are made in both the US legal system and how health insurance is marketed and sold, meaningful change doesn’t have a prayer.

How would tort reform help? Defensive medicine – practicing medicine with one eye over your shoulder looking for lawyers – adds as much as $45.6Billion-with-a-b annually to US spending on healthcare, according to a Harvard study published in September. That may seem like a drop in the bucket when the total annual spend on healthcare in this country is $2.3Trillion-with-a-t, but those dollars are all coming out of our pockets one way or another. Whether it’s in higher health insurance premiums, deductibles, fee increases to help providers cover those who can’t pay, fee increases to help defray the costs of malpractice insurance, or tax dollars for Medicaid and Medicare, we pay for it.

Reducing the dollar impact of medical liability would start to address some of those costs. Tort reform would give providers a defined worst-case scenario for liability, and would reduce the sue-the-bastards incentive for patients (and their lawyers) who don’t get the outcome they want from treatment. There are no guarantees in medicine, other than that there are no guarantees in medicine. Patients who are harmed by doctors that are unfit to practice wouldn’t be left without recourse, but the dollar amount of settlements would be capped.

Now, on to my really controversial suggestion: severing the link between health insurance and employment. Employer-paid health insurance benefits weren’t common in the US until World War II, when stiff wage controls made defense plants and other employers get creative to attract and keep good employees. They came up with offering to pay for workers’ health insurance. Thus was employer-sponsored group health insurance born, and the individual health insurance market stamped with an expiration date.

If you’re selling something, wouldn’t you rather package and sell it to as large a group as possible? Insurers, helped along by federal labor laws, have had a great revenue model: sell to large employers, keeping their annual premium-per-employee at an acceptable level because of the size of the risk pool. Cherry-pick the individual market, and put a high price tag on coverage for individuals who look like they might get sick – like women.

I’m actually quite pleased with one of the provisions in the health care reform bill fines employers with 50 or more employees $2,000 for each worker if they don’t provide health benefits. Why? Because the largest US employers – Walmart 1,000,000+ US employees, Verizon 200,000+, UPS 350,000+ in the US, to name a few – will look at that figure, do the math, and discover that the fine will save them money.

Again, for the math challenged: 1,000,000 employees would cost Walmart $2Billion-with-a-b in fines. Sounds like a whacking huge amount of money…until you calculate the cost health insurance benefits for those 1,000,000 employees using the average premium, which runs between $4,000 (single coverage) and $10,000 (family) per year. The fine would save Walmart $6-8B a year. They could even offer their employees help buying coverage, and still save some serious money.

And break the tie between group coverage and employment.

What would happen then? I think the American people can get together and drive the market as one big coast-to-coast group, using consumer-driven health plans (CDHPs) combined with health savings accounts (HSAs). I believe that one of the causes of the healthcare cost conundrum in the US is the passive attitude most Americans have about their health, and healthcare. Decades of coverage paid for with “other people’s money” (employer-sponsored plans) have turned us into a nation of mindless medical consumers. We want cutting-edge care, we want second, even third, opinions, we bitch about $100 co-pays, we want to never have a bad outcome. Oh, and by the way, we don’t want to pay for it.

CDHPs would help make us mindful again: about the costs of healthcare, about the impact of our choices and behavior on our health, about how to get the most value for our healthcare dollar. A consumer-driven plan – also called a high-deductible plan – has a lower premium than traditional PPO or HMO plans due to that higher deductible. It also has no co-pays. You pay for care until you max out your annual deductible – between $1,000 and $5,000 per year – and are fully covered after that. Some CDHPs cover preventive and screening care, like annual physicals and mammograms, outside the deductible.

To be truly effective, CDHPs must be tied to HSAs, both to help consumers pay their deductible costs and to encourage them to save money for future healthcare costs. Making HSA contributions with pre-tax money makes HSAs “IRAs for healthcare,” with tax penalties for non-healthcare withdrawals. Since consumers – patients – will be paying for healthcare out of their HSAs, they’ll have an incentive to both ask what a procedure or prescription costs, and to ask questions about the cost of treatment options.

We’re a consumer nation. We shop for deals on flat screen TVs, cars, iPods, and breakfast cereals. Isn’t it time we did the same thing for prescriptions and hospital costs? I for one would jump at the chance to enroll in a CHDP – unfortunately, they’re not offered to individuals in the state where I live.

Don’t get me started on state insurance commissions…

In addition to this video, the Kaiser Family Foundation has great resources/basic information to help you understand the new law. To access this information, click here.

I find this an instructive analog to the first fatal flaw in health care for profit. If I am engaged in such an enterprise, I am obligated to make a profit. Each year I am expected to meet or exceed last year’s profits. That requires that I continuously decrease expenses and expand my yield. If I fail to do so, I will go out of business or at least lose my stockholders and my stock value. I can never let up on profit expansion. My first best option in decreasing expenses is to cut back on major categories, such as personnel, the big budget item.

I then demand greater productivity. We did this in health care in the 90s when our national average for cutting nursing personnel in hospitals was 9%, while concurrently shortening length of stay with concomitant dramatic increases in patient acuity. Greater productivity not only evokes employee dissatisfaction; it also leads to stress, fatigue, and ERRORS. These errors are expensive. We begin to self-destruct. (I would suggest that this is the maze of horrors much of corporate America finds itself in today; most interestingly, they also now have eliminated so many workers that there is no one to buy their products because unemployed people cannot make purchases…see, it is irrational!)

The second fatal flaw that no one acknowledges is of course that another great way to make a profit is to withhold services. Insurance companies understand this. Hence, finding ways to game the system makes sense. They need to make a profit and delivering services costs money. No matter how dedicated they may be to quality health care, it is in their self-interest to deny services whenever they can. It is easiest to do this with the poor, powerless, and disadvantaged. They are less likely to raise a ruckus, and if they do, we can count on dominant groups to ignore them. After all, this profit making is our driving value, we need to serve our stockholders, and there will be acceptable collateral damage in our push to succeed. Besides, poor people might now even know they have received fewer services.

The third fatal flaw for me focuses on the most daunting of patient populations, the indigent mentally ill. No matter how many people sing the praises of Ronald Regan, for me he will always be the man that dismantled care for indigent mentally ill persons, normalized homelessness as an acceptable alternative for these sick persons, and adapted prisons as the “other” alternative to homelessness when necessary.

By definition, indigent mentally ill persons without treatment cannot function. One can make righteous comments about “boot straps” forever and that does not change this fact. As neuroscience, among other great endeavors, unveils how often mentally ill persons cannot “will” themselves into a healthy state, one then has to ask how they can get treatment. Certainly their care will not generate a profit.

The final fatal flaw is the one that I fervently wish would save us from ourselves. Making a profit on the suffering of others is simply obscene. It is inhumane to withhold care from people because they are not likely to generate a profit or their care is too costly. Yes, this is a moral argument, and I am increasingly struck by our collective willingness as a nation to insist that moral conduct is a luxury, perhaps naïve or childish. To take a stance on moral principle is increasingly viewed as negligent of the bottom line. There is something downright creepy about this drift.

This month Reuters published the results of a study comparing “Catholic, other church, investor-owned, and not-for-profit hospitals”. Their results validate my observations to some degree. “Overall, Catholic and other church-owned systems were listed first and second respectively in terms of being significantly more likely to provide higher quality performance and efficiencies to communities than investor-owned systems. Investor-owned systems demonstrated lower quality performance than all other groups.” This report did not make the front page of the Wall Street Journal.

Lest you think I am making the case for government run health care, I would observe that the private sector could control all of health care. In particular, we might want to find ways to preserve our Catholic and church owned hospitals. Perhaps they have value positions that influence their choices…hmmmm.

My argument is that health care should not be a for-profit enterprise. If you have read thus far, I congratulate you. In our current befuddled state as a nation, we are not even having this discussion. It is assumed that health care for profit is the wave of the future. Heaven help our grandchildren!

This month’s health insurance issue: Linda is having surgery in the morning, but at 4 p.m. the afternoon before, she gets a call from her HMO requiring her to post a $400 advance deposit — or the surgery is off. What should she do?

The situation: Our client Linda was scheduled to have surgery using a surgical group that had negotiated fees with her HMO carrier. Besides being told to post $400 in advance, she was told she needed to sign a form stating she would pay whatever fees the carrier would not pay to the doctor.

This came despite the fact that the surgeon was in her HMO network and Linda had gotten the proper referral and authorization from the carrier. In fact, her policy dictates that when a provider has signed a contract with an insurance carrier, the patient is held harmless from all fees associated and cannot be asked for additional payments other than applicable copays, deductibles, and coinsurance. In this case, the policy had a $20 doctor copayment and 100% coverage, with no hospital copayment.

Linda called us in a panic, and we immediately phoned our contact at her HMO. Due to the late hour, our contact couldn’t do anything until the following morning, when she would have a representative from provider relations step in. And after a long discussion with the insurance company, Linda did not have to post the deposit and did have a successful surgery.

The solution: Don’t assume anything before having surgery. Get on the phone and make sure you are covered.

1. Contact the insurance provider and verify all benefits. Always get the name of the representative you talk to, as well as the department name and number. Try to speak with a supervisor. Also, note the date and time you had the discussion, since all calls are recorded and can be pulled to make sure accurate information was given.

2. Get all pre-authorization agreements in writing. Typically, the doctor’s office will call, but you should insist on getting it in writing, too, so you can be sure everyone involved in the surgery — the surgical center, hospital, anesthesiologist, doctors, etc. — is covered by your health insurance plan.

3. Understand your policy and be clear about the items that you may be required to pay for. Many hospitals, surgical centers, radiological providers, and labs will send you a bill in addition to submitting it to the insurance company. Remember:: Never pay a bill unless the insurance company has received it first and re-priced it (including applicable discounts) and until you have received evidence of benefits that match the bill.

The painful truth: Unfortunately, the system is broken. Insurance carriers, doctors, and patients will continue to eek out whatever they can from the health-care and insurance system until new policies are in place that make it clear exactly what the contract is that they are entering into. If anything is unclear in your agreement, a new one needs to be worked out that will include cost, payment, and what insurance covers.

If we were the Health Insurance Ambassadors: We would require that all doctors notify the patient about the exact cost of the surgery before the procedure. The patient would then have a full understanding of the costs associated with the surgery and the doctor would receive the appropriate payment.

In defense of doctors, we would also change how they take payments. Doctors do not ask for money upfront. They provide a service and hope that they will receive payment afterward. Perhaps they should swipe a credit card before the procedure or at the time of an office visit.

Originally posted on http://www.beinkandescent.com/articles/251/scott-golden-and-stephanie-cohen.

I say “once upon a time” because today, that scenario is mostly a fantasy.  And sadly, today’s story doesn’t always end with happily-ever-after – for anyone.

Providers went to medical school to learn to heal and help. Instead they carry excessive patient loads amidst decreasing reimbursements, spend a small fortune on malpractice insurance, and reject some patients who don’t have the right kinds of payers, or who take up too much time with difficult diseases or comorbidities. They are frustrated with their inability to deliver the care they prefer to deliver, but they must protect themselves or they will lose their practices.

Since the passage of reform, insurers have been forced to realign their requirements and services so they can continue to suck money from employers, patients, providers and the government. They spend billions on lobbying efforts, and reduce their provider reimbursements – at the expense of patients who are continually denied the care they need. A million families go bankrupt each year because they erroneously believed their insurance would cover their care when they needed it.

Those patients, accustomed to provider paternalism and decent payment coverage, find themselves blindsided to this devolved system that no longer provides the care they need and deserve. They get sicker. They die from medical errors. They lose their homes. No one has ever even suggested, much less taught them how to stick up for themselves or take responsibility for their own medical decision-making.

Patient Advocates to the rescue! Patient advocates are the only participants in the healthcare equation who may deliver improved outcomes for everyone  – providers, payers and most of all –patients.

When an advocate accompanies a patient to an appointment, less time may be required because the advocate will facilitate communication and the process. In a hospital setting, a bedside advocate will double check drug dosing and insist on hand washing, keeping the patient safe and providers out of hot water.

Payers benefit from the efforts of patient advocates, too.  Advocates help patients understand when a generic drug makes sense, or question a diagnosis before the wrong treatment is dispensed or performed, and therefore must be reimbursed. A billing or claims advocate knows how to file paperwork correctly, or reduce a hospital bill, saving time and expense for payers and patients.

Of course, advocates provide the biggest benefits to us patients. We can rely on our advocates to be focused on our improved outcomes and well-being.  Just like – once upon a time — we relied on our doctors.

Talk about disruptive! Rare is the case that an extra person in any relationship can improve the outcomes for everyone involved. 

But this is no fantasy. Patient advocates are skilled and ready to help.  Including an advocate in the medical care delivery equation can help us refocus on the possibilities of the good care that providers wish to deliver, payers are willing to pay for, and patients deserve to get.

My husband suffered a stroke that resulted in speech and mobility impairments around the time that the ADA became law.  The ADA continues to help my husband and family by increasing awareness and accessibility for people with disabilities to fully participate in our community, to go to school, work, shop, movie theaters, restaurants, and hotels, to use public transportation, to access hospitals and health care, and to have a place to call “home.”

The ADA rights also extend to caregivers of people with disabilities.  Balancing the demands of a full-time job and taking care of a family member with a disability or chronic illness can be difficult, even with the most understanding employer. Under ADA caregivers, male or female, are protected from job discrimination resulting from real or perceived family commitments.

I remember during an interview for a job found through networking, my potential supervisor — who knew that my husband had had a stroke — asked me how I would manage to travel.  I was very proud of my husband’s independence, and assured the supervisor that it would not be a problem. Although I got the job, I realized that discrimination against people with disabilities impacts their family as well.

The Federal Equal Employment Opportunities Commission (EEOC) published guidelines based on the ADA stipulating that employers cannot give different treatment to caregivers during the hiring process, job reviews, work assignments, or promotions based on stereotypes of caregiving responsibilities. Section E and F of the guidelines, and examples 17 and 20 relate directly to caregiver protections under the ADA. For a copy of the “Enforcement Guidance: Unlawful Disparate Treatment of Workers With Caregiving Responsibilities,” visit the EEOC website at: http://www.eeoc.gov/policy/docs/caregiving.html

To join the celebration of the ADA’s 20^th anniversary, visit any of these websites:

http://adaanniversary.org

http://www.ada.gov

http://www.ncd.gov

http://www.disability.gov

http://www.ncil.org

You’re Invited to

“Solutions To Scale: Proven Health Care Models for Primetime”

 Wednesday, June 30, 2010

 9:00 – 11:30 am

Breakfast will be served at 8:30 am

Kaiser Family Foundation

Barbara Jordan Conference Center

1330 G Street, NW

Washington, DC 20004

 Raise the Voice, a program of the American Academy of Nursing supported by a grant from the Robert Wood Johnson Foundation, showcases the work of “Edge Runners” – nurse researchers and experts who have developed proven care models and interventions that demonstrate significantly improved clinical outcomes and cost savings.  The Edge Runners will share their experiences to highlight what does and does not work for consideration by federal and state agencies during health care implementation.

Welcome:

• Diana J. Mason, PhD, RN, FAAN, Editor-in-Chief Emeritus, American Journal of Nursing
• The Honorable Robert Borski

Opening Remarks:

• Ken Thorpe, PhD, Department of Health Policy and Management, Rollins School of Public Health, Emory University

Panel One:

• Tina Johnson, CNM, MS, Practicing Nurse Midwife
• Tine Hansen-Turton, MGA, JD, CEO, National Nursing Centers Consortium, Executive Director, Convenient Care Association, Raise the Voice Edge Runner
• Eileen M. Sullivan-Marx, PhD, CRNP, FAAN, Advisor, Living Independently For Elders (LIFE), Raise the Voice Edge Runner
• Deirdre Baggot, BSN, MBA, Administrator for Cardiac and Vascular Services, Exempla Saint Joseph Hospital, CMS ACE Demonstration Site for Bundling Payments
• Sandra Haldane, BSN, MS, RN, Chief Nurse, Indian Health Service

Panel Two:

• Randall Krakauer, MD, FACP, FACR, Head of Medicare Medical Management, Aetna
• Susan Reinhard, PhD, RN, FAAN, Senior Vice President, AARP Public Policy Institute, Chief Strategist, Center to Champion Nursing In America
• Matt Salo, Director Health and Human Services Committee, National Governors Association

Moderator:

• Scott Hensley, National Public Radio

RSVP: Joy Burwell 202-263-2971 or jburwell@amplifypublicaffairs.net

Sponsored by the American Academy of Nursing’s Raise the Voice Campaign. Raise the Voice is supported by a grant from the Robert Wood Johnson Foundation

In grad school it helped me stay focused – and calmer – through killer statistics classes. Later, it was a way to unwind at the end of a workday. Still later, it saved me from surgery to correct fairly severe scoliosis. It’s not cured the deformity but I’m virtually pain free most of the time – no small feat for one who spends 18-24 hours on flights and 8 hours standing to facilitate meetings.

More disclosure – I am certified to teach, though I don’t. The same erratic travel schedule that prevents attending classes on a regular basis precludes committing to teaching them. I trained to be able to practice on the road. It was a good investment of my time and funds.

Yes, my time and funds. Anyone familiar with yoga knows that for the most part, students pay a small amount for a class – or series of classes – out of their own pockets. Sometimes, yoga is offered in schools, hospitals, churches, workplaces and prisons and the cost partially or fully paid by some third party. Sometimes teachers donate their services as part of the ‘selfless service’ that embodies the lifestyle.

Recent weeks presented an interesting confluence of events in my life as a yoga-practicing health policy analyst: health reform passed and Yoga Journal published a major article on methods, issues, controversies and implications of yoga research.

I started a yoga research literature review a few years ago. It was to be the opening chapter of an adaptation of my grantseeking guide (see www.strategichealthpolicy.com for a free download), revised and updated for yoga teachers intending to seek and secure third-party – including health insurance – financing support for classes.

I abandoned the project for many of the issues raised in the Yoga Journal article: research methods were relatively undeveloped, uncontestable positive results were scant and within the yoga community both were controversial. That’s right, even the need for research to demonstrate the value of yoga is controversial. Many thought there was proof enough.

Proof enough for an individual to pay? Yes, that’s been well-demonstrated. Thousands of times each day, people around the world pay out-of-pocket to attend classes. Proof enough for a third-party to pay? Far from it, at least as we have defined proof within the American health care sector.

Now, the health reform era is upon us, some people will press for yoga services as a covered benefit and if a serious discussion takes hold – and succeeds – in adding yoga to American health care armamentarium, yoga teachers will face issues common to other product and service providers. Clearly, not all yoga teachers will want to participate and none will be forced, but those who choose to do so will need to address – at a bare minimum – questions commonplace to physicians, hospitals and drug companies:

First, is yoga effective? Any prevention or treatment modality used in health care is expected to be safe and effective, demonstrating that it performs as advertised, promoted and hoped.

That means prospective research, such as trials comparing yoga against a non-intervention, a placebo or a standard therapy treatment, or a study of a sufficiently large population through ‘natural observation’ to gather similar evidence over many years.

Research such as this will raise questions about whether the ‘style’ of yoga matters, how many sessions might be required to achieve results and whether results last after classes are stopped. People in the study will be carefully selected and ‘assigned’ to each intervention group. They’ll be asked about other aspects of their lifestyle to assure that they’re not confounding the results with other possibly-effective therapies.

Side effects will be monitored. Injuries in class or suicidal thoughts outside of class (if any occur) will be noted so that cautionary warnings and contraindications can be addressed in coverage and reimbursement decisions. Other unintended consequences – weight loss comes to mind – will be documented but can’t be claimed a benefit unless the study was specifically designed to test for it.

Research might also need to tease out yoga’s “mechanism of action” as is the case for medications; for example, by what mechanism does yoga breathing techniques reduce hypertension?

Researchers will be required to seek approval from Institutional Review Boards protecting patients, may be required to vet research methods with regulators or payers, will likely be required to disclose financial interests in yoga and if any are found might be precluded from doing research and/or might be restricted from committees that address yoga policy and financing issues – all to assure research subjects are protected and conflicts-of-interest are prevented.

Second, is yoga cost-effective? Having passed the first hurdle regarding effectiveness, yoga would then be subject to a test of relative value against other therapies. This will likely be determined by a combination of cost and patient satisfaction factors. Yoga is less expensive than the spinal surgery I faced and I’m very satisfied not to have suffered the projected month of hospitalization, surgical risks and likely post-surgical pain. In fact, had I not learned yoga, even daily classes – were I to pay for them – would likely cost less than the pain medications that might otherwise be a staple of my day and would be immensely cost-beneficial over the disability others in my family have faced.

Could the same be said for hypertension? Generic medications cost only pennies per day and require only seconds to swallow, at far less cost and time investment than a yoga class or daily practice. In fact, even brand products are likewise less expensive and easier to comply with than a regular yoga practice. No therapy is effective – and is certainly not cost effective – if patients don’t use them. Medication adherence can be as low as 50%; are there data to show how yoga compares? If yoga is judged by payers to require more of patients who will not likely adhere to the regimen, payers may be skeptical and reluctant to cover it.

Third, how will yoga teachers and studios be regulated? It’s not a question of ‘whether,’ but ‘how’ requirements will be framed through regulations and provider contracts, and what group will monitor compliance with those.

Products and services reimbursed by Medicaid and Medicare, purchased with federal or state health funds, distributed through the VA, Community Health Centers, Indian Health Service, and Public Health Departments must comply with certain conditions and those will likely apply to yoga as well. Non-government third party payers set their own, similar standards.

Payers want to know they’re financing the activities of legitimate providers of care capable of assuring access and quality at a good cost, adhering to acceptable practices of promotion and protecting against fraud. This will happen through regulation and contractual agreements with providers that will address.

Quality

• Will yoga teachers, as ‘providers’ of health care, be subject to standards beyond those of their training schools?
• Will they be subject to state licensing (as are other providers and facilities), credentialing, periodic re-licensure and re-certifications, continuing education requirements and personal background checks?
• Will yoga teachers be required to collect and report injuries or adverse events sustained during classes, as do hospitals or pharmaceutical companies in reporting injuries and adverse events? If so, will those be published in increasingly-familiar formats like report cards on providers?

Access

• Will yoga studios, as a ‘setting’ of health care, be subject to requirements for access for special populations such as children, seniors and the disabled?
• Must yoga address non-financial barriers (e.g., language)? Government-funded providers must treat patients in their language – providing translators if needed. Must yoga teachers do likewise?

Cost

• To control for appropriate use, will a prescriber order be required, much like for physical therapy?
• Will the number of reimbursed yoga classes be limited, much as other visits for psychotherapy or physical therapy?
• Will payers require pre-authorization for yoga classes, such that the prescriber or yoga teacher will need to justify a prescribed number of classes, or additional classes for some patients?
• How will the fee for a yoga class be set? Will the rates be negotiated? Or set by the payer?  Will government get the ‘best price’ through rebates, competitive bidding, volume purchasing or price controls?
• If only a portion of the class fee is paid by a third party, may teachers collect the difference from the student/patient, or as in Medicare will they be prevented from doing that?

Marketing and Promotion

• How may yoga be marketed and promoted?
• Can claims be made for health outcomes without clinical evidence to demonstrate its validity? What endpoints are satisfactory to prove the claim? For example, is ‘toning muscle’ or ‘developing balance’ a satisfactory endpoint or must reductions in hip fractures from falls be demonstrated?
• Can one form of yoga claim superiority over another, and if so, under what criteria and circumstances?
• Must all promotional claims also include a list of possible injuries to assure ‘fair balance’ or ‘informed consent’ and clear warnings to patients?
• Will promotion to health care providers be allowed and if so, of what type? Sampling? Reminder items? Continuing medical education?

Fraud Protections

• Will yoga teachers be required to transmit class attendance information and provide progress reports to payers that provide coverage and reimbursement?
• Are payers entitled to know how often – and with what results – patients attend classes?
• Will yoga providers be required to link class attendance to electronic personal health/payment records?
• How will payers audit records to assure that billing matches the actual class attendance by covered patients?

Some payers – as businesses do now – may choose to offer yoga and never address the issues raised here. In my own company, for example, having seen the value for myself, I’d gladly underwrite the cost for my employees. The same might be true for even a very large company.

If yoga ‘goes mainstream’ in health care, however, it is likely that it – and other ‘alternative’ modalities – will be scrutinized. I know both sides and can envision a dozen questions more than the ones posed here.

It’s not my place to say what is best for yoga in America, its students and teachers, or what’s best for health care in America, its patients or payers.

A match made in heaven? It’s too early to tell. Time will. OK everyone, relax, take a deep breath….and another….

The law is intended to require insurers to issue policies that provide a full range of benefits for all children with pre-existing conditions starting in September 2010.  That means insurers can no longer refuse to cover children with pre-existing conditions under their parents’ plans, even if the children never had insurance.

This law has far-reaching ramifications.  A recent story about a newborn who was denied coverage at the age of a mere 9 days highlights how critical this law is.   Born with a congenital heart defect, Houston Tracy underwent lifesaving open heart surgery when he was just 4 days old.  His parents cannot afford insurance for themselves, being small business owners, and have individual policies for their older two sons.  After being charged and given the run-around by the insurance company, they resorted to enrolling their newborn in the state’s high-risk pool.

The big question now is how much will insurers charge for these policies.  If the price tag is too high, parents will not be able to afford to purchase policies, and in effect, coverage will be denied to these children.

It is not clear whether HHS regulations will speak to this issue.  The administration will be watching the insurance industry closely.   So will we.

By Stephanie Cohen.  This month’s health insurance nightmare: Dad is still paying for his daughter’s insurance — and no one is happy.

The situation: I received a call last week from a client whose daughter recently told him she hates her insurance “because it does not cover anything.” He phoned me to see if she had a real gripe, and if I could help him find another policy with better coverage for her.

The problem: It turned out that her policy had a $5000 deductible, which did not include coverage for dental or vision doctor visits. Since she has an entry-level position and not a lot of extra spending money, I told her she had a choice.

She could choose to pay more per month to lower her out-of-pocket expenses, but her monthly premiums would be higher. Since her father was paying her premium, and was happy to do so, I decided the best policy for her was one with a higher premium and lower expenses.

The solution: The decision to pay for an adult child’s health care is a personal one that each family must make, of course. The reality is that once a child turns an age selected on the policy by the plan administrator based on the rules of the state and the size of the employer, they are no longer considered a dependent.

Many times, the insurance company does not notify the parent or the plan administrator that the student has been dropped. The student typically finds out when filling a prescription or when receiving services. 

Keep in mind that it is the parents’ responsibility to notify the carrier that the student is or is not a full-time student and is eligible for coverage. The student is responsible for having a student certification form completed and signed by the bursars office proving they are in school fulltime with 12 plus credits.

If I were the Health Insurance Ambassadors: All students would have to prove they had coverage or they could not attend school.

Although with the recent health reform legislation there is now a new Federal mandate to allow children to be on their parents health plan until 26, it still may be less expensive to insure that child unto themselves rather than remain on the parents plan.  Obviously, the rates will be much lower for someone who is much younger.

The painful truth: Parents can analyze the cost of coverage through the school or an individual policy versus the cost of keeping the child on his/her plan. If the parent has other children on the plan, it rarely saves to pull one child off the plan.

 I encourage you to share your insurance nightmares with me.