By Stephanie Cohen. This month’s health insurance nightmare: You believe the cost of your policy is too high and the benefits too low.

The situation: Sara E. was looking at new insurance options because she was concerned that her current policy cost too much and covered too little. A case in point was a recent eye exam. She had to pay for the appointment because she hadn’t yet met the $1000 deductible on her current policy.

The solution: It was clear that Sara did not understand the details of the policy she had purchased. It’s not unusual, but can prove problematic. In fact, we recommend that all of our customers make a list of the medical services they will likely need throughout the year. Before buying anything, we tell them to read the fine print on the policy and ask questions until they are certain they understand what they are paying for – and what will be an additional charge.

Here’s why: The fine print on an insurance policy can be complex. The bottom line is that if you purchase a policy with a high deductible, there will be no coverage until the deductible is paid in full. Deductibles apply to all coverage if you purchase an HSA (Health Savings Account) compatible plan – except for preventative services.

And realize this:

1. Deductibles can also apply to specific services such as lab work and hospitalization.

2. They also apply to services differently depending on whether they are in or out of network.

3. It’s important to know that deductibles may be cumulative or shared, or based on the calendar year or contract year. Know how it works for the policy you purchase.

4. If the policy is a Health Savings Account (HSA) versus a high-deductible plan, you will be able to write off the amount placed in the HSA account up to the maximum allowable by the government. The minimum deductible for HSA plans start at $1200 for a single and $2400 for a family.

5. Do note that there are many after-tax expenditures such as those that are included in the FSA Section 213 of the tax code, which can be written off that are not covered under an insurance policy, which is the advantage of an HSA.

If we were the Health Insurance Ambassadors

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Every January, new billing rules and rates go into place for physicians’ services as part of the annual update to Medicare’s Physician Fee Schedule. Dominating DC health policy concerns in this arena are the medical community’s efforts with Congress to address Medicare’s cost-of-living adjuster, known as the “sustainable growth rate” (SGR), which would have lowered 2010 fees across-the-board by 21 percent, if not for a last-minute temporary stay through the end of February. Negotiations with Congress are on-going to provide a long term or multi-year solution—a costly “fix” that I believe is well worth the price to keep physicians in the Medicare program, and seems to have widespread support.

Getting much less attention is a unilateral policy pronouncement made by the Centers for Medicare and Medicaid (CMS) that Medicare will no longer pay specialists a higher rate for consultations—services often provided by specialists like cardiologists and neurologists. Instead, all physician visit services, whether defined as “evaluation and management” (E&M) services or consultations, will be reimbursed at the same E&M rates. (more…)

Healthcare (insurance) reform has passed in the Senate and final negotiations are happening before it moves on to the President’s desk for signature. While the legislation is not perfect – in fact some would say far from perfect – it is a piece of legislation that is very much in keeping with our American philosophy, our constant pursuit of progress and change.

As the late Senator Kennedy’s career on Capitol Hill demonstrated, change is usually incremental, usually negotiated and usually compromised. But at the end of the day, change usually amounts to progress.

I see tremendous progress, too, as I look back on a decade’s worth of work to promote access to affordable quality health care using nurse practitioners in the role as primary care providers, thereby alleviating the burden on a strained primary care system.

We’ve come a long way regionally and nationally. The fact that we as a country are always striving to improve our path is what most invigorates me as a relatively new American. Our pursuit of progress is never ending, but it is what sets us apart from most countries in the world. We know our work is never done. As we enter a new year and decade, we always should remember that what makes us different from most people and countries in the world is that we have the freedom to purse progress and make change.

This health insurance reform bill is not the end all or be all, but it will help make affordable health insurance available to more than 30 million Americans who have been without it. Furthermore, the legislation contains many provisions for others who fall through the cracks and will need additional care and support.

That’s progress for individuals, families and America, as Walt Disney would have said. And not until you take a ride on the Magic Kingdom’s The Wheel of Progress will you truly appreciate how important it can be to take even a small step in the right direction.

Happy New Year! And a toast to a New Decade and our new Pursuits of Progress for individuals, families, and our country.

Healthy New Year everyone!

Like many people I’m starting the year with healthy – and preventive care – intentions. How about you?

That put a few items on my holiday ‘to do’ list:

• Get a pap smear,
• Find H1N1 vaccine,
• Wrestle the results of a recent bone density scan (Dexa) out of the hands of the medical center and into the hands of my physician, and
• Confirm with Morris White, my trainer, that I’d continue workouts.

The pap smear was easy – this time. I’d not been able to get one during my late-summer vacation visit to the doctor because the appointment was two weeks prior to the annual date of the prior test. That required another trip. Holiday downtime was a good time to do that. Check that off the list.

In doing so, I finally found an H1N1 vaccine dose! Getting a seasonal flu shot was easy at www.phillyflushots.com, but even after calling several immunization providers and both of my physicians at least twice monthly since H1N1 became available, checking websites and following news reports of shots at pharmacies – well, no success. Luckily, my doctor had just received a few doses of H1N1 that day of the pap smear. Check that off the list.

Results of a bone density scan months ago had still not shown up at my doctor’s office. Holiday time was a good time to badger for the ‘results,’ though it was hardly worth the trouble. Turns out  my physician is not part of that medical center’s ‘network’ and can’t get detailed results. Only a note: ‘normal.’ Sorry, that’s not good enough. Neither my physician nor I know whether there has been any change in bone mass since prior tests. Sure, the test results might be ‘normal,’ but the measures might also be trending in a direction that means I’m losing bone mass, something we both should know about. No check there, still on my list.

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Think you have maternity coverage? Think again.

Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because I think Disruptive Women readers will find it useful, each month I’ll post an example of a health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.

My goal, however, is to find a way to improve health insurance for beneficiaries and I have some suggestions at the end of this post.

This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation: When our client, Ms. R, found out a few years ago that she was having a baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits. Making the call was merely a formality. When she originally purchased the policy, she was single and didn’t opt for the maternity rider. After she got married, she added maternity coverage because she wanted a family.

Indeed, when she called the insurance company, they confirmed she had the insurance she needed. However, after her first OB check-up she received a letter saying she was, in fact, not covered.

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In the face of acute primary care physician shortages and steady reductions in the number of physicians who are willing to accept Medicaid and Medicare, it is unclear whether our existing primary care system will be able to meet the needs of a universally-insured nation, as President Obama has expressed as a priority for his Administration.

Health care delivery is strained under tremendous pressure from the demands of chronic health issues, downward trends in third party payments, and while insurance coverage will address some of these issues, many of these problems may persist even if universal insurance coverage is achieved in the United States. So what else needs to happen to make healthcare reform a success?

In recent years, a series of “disruptive innovations” in the health care sector have capitalized on non-physician providers, such as nurse practitioners, and their ability to provide high-quality primary and preventive care in retail-based settings such as Convenient Care Clinics (also known as retail-based clinics) and in community-settings, such as Nurse-Managed Health Centers. Research in Health Affairs and other peer-reviewed journals has documented that retail based clinics and Nurse-Managed Health Centers provide safe, accessible, affordable care to millions of Americans without threatening continuity of care. Nurse practitioners practicing in these independent settings already touch millions of people annually. Thanks to regulatory reforms that have taken place over decades, including those led by governors in Pennsylvania and Massachusetts, nurse practitioners are legally authorized to prescribe medications and provide care that is a comparable in scope to that of a primary care physician in all 50 states.

Consumers gravitate to both models because they are accessible, affordable, provide quality care but most importantly, they are convenient in their locations, hours and ease of use. For healthcare reform to be successful, we need to embrace these disruptive innovations. We also need to maximize the amazing, high-quality provider workforce we educate in our finest academic institutions across the country. Nurse practitioners and other non-physician providers (such as physician assistants, pharmacists, and psychologists) are eager to partner with their physician colleagues to expand access to care for all Americans and make the Administration’s healthcare reform effort the success it needs to be!

The U.S. Preventive Services Task Force unleashed a tsunami this week with new breast cancer guidelines that are suspiciously timed to current efforts to rein in burgeoning healthcare costs. Indeed, the recommendations appear to be geared towards reducing overtreatment by eliminating what the Task Force considers unnecessary follow up screenings and tests. The recommendations even suggest the breast self-examination (BSE) should be discontinued.

In essence, what the Task Force concluded was that while screening reduces deaths from breast cancer, it does not save enough lives to justify associated costs.

To exacerbate the controversy, the American Cancer Society has publicly stated that it does not endorse Task Force recommendations and in a detailed analysis suggested that in the review of the evidence, the committee got caught up in semantics (i.e. risk versus benefit) and that at the very least, computer modeling may be flawed in terms of its ability to translate statistical data into real life.

Meanwhile, the New York Times reports that many doctors are ‘staying the course,’ and in between anger and disbelief, women across the nation are crowding the phone lines trying to discern what is true and what’s not.

Have we all gone mad?

Obviously, these new recommendations will be echoing in the halls of hearings that will determine the future role of mammography in government-run health programs, private insurance programs and the current healthcare reform initiative. Already, Congress is calling for Hearings. But more importantly, is the debacle is a prime example of what ails our healthcare system and reflective some of the more important changes that must take place if we are ever going to move forward in a way that benefits all the players. Truly, who’s really in the driver’s seat?

The fact is that although nearly 250 million Americans do have health insurance, according to a monthly survey of about 50,000 households done by the Bureau of Labor Statistics and the Census Bureau, an estimated 46 million Americans do not.

Listed below you’ll find arguments for not having health insurance that I hear on a regular basis. As a broker, I’ve provided a reality check for individuals to consider before making their final decision.

1. It costs too much.

The reality: Should a catastrophic illness or injury occur, it would likely bankrupt most people who do not have health insurance. It’s the terrible fact of life in 2009. Medical care is incredibly expensive, and employers are increasingly less likely to be able to support an injured or ill employee. So if something happens to you, and you have not saved enough money to support yourself if you are unable to work, odds are good that you will be in debt for astronomic health care bills and, unfortunately, many of us would be hard pressed to ever climb out of that financial hole. Don’t be scared. Just think long and hard about that.

2. It does not cover all of the health care needs that I have now, or might have in the future

The reality: The truth of the matter is that a good health insurance broker can usually find a policy that covers most every medical problem that is likely to arise. There are also resources that can be used to supplement your plan. For instance, if you need discount drugs, it is possible to fill your prescription at Wal-Mart or in Canada. Need a flu shot? You can get one at your local pharmacy. My mother always told me, “where there is a will, there is a way.” I believe that to my core. You just need to be clever and work at solving your own problems.

3. The drug benefit is insufficient on most health care plans.

The reality: See above. And do remember, you are your own best health care advocate. The health insurance plans cover many things, but you need to do some legwork to get everything you want and need for your own care.

4. The process of finding the right health insurance is too complicated.

The reality: Honestly, it really is not. Think about the old adage — “How do you eat an elephant? One bite at a time.” The same applies to health insurance. People think that the process of understanding a policy is just too difficult, so they tend to shut down before they even try to take the time to comprehend it. Don’t give up too soon.

5. I have a specific health issue that was not covered satisfactorily in the past, so I’m not inclined to buy health insurance again.

The reality: Please realize that not all policies are the same. There is definitely one that is right for each individual. Plus, there are often state-run programs that can address most insurance needs. If you had an issue it is likely that someone else did too, so take solace in the fact that you are not alone.

6. I am healthy and do not need health insurance today.

The reality: That’s true. Until, of course, you do need it. You will. You are human. Humans get sick and often need to see a doctor. So please, do not be stupid. Protect yourself against what is more than likely to come. In the case of a catastrophic incident, this ignorant assumption cannot be undone.

7. Obama will help me get free insurance.

The reality: I cannot believe how many times I have heard this in the last few months. I am the first to admit that President Obama is doing his best, but please stay grounded in the facts. The U.S. government is not going to give everyone a free health insurance policy. Unless you are very poor, forget this as an option. Take care of yourself today and buy an affordable health insurance policy.

8. I want to wait until health insurance is cheaper.

Having been in this industry for more than two decades I can speak from experience that health insurance companies are not in business to help you. Insurance is not going to get any cheaper — at least, not any time soon. It is heretic to admit, but insurance companies do not make billions for their shareholders by helping the little guy. We are easy targets. We have no lobbying power, and they know it.

The bottom line: Be smart. Buy a health insurance policy that will at least cover you in case of a catastrophic event. Health Savings Plans are a good option, and more solutions are coming on the market. The bottom line is that if you take care of yourself, you won’t regret it.

As I mentioned in my post last week, Disruptive Women in Health Care is tackling the issue of drug adherence, often referred to as America’s other drug problem.  From a health policy standpoint, the issues cross financial, clinical, behavioral, and cultural boundaries.

Over the next two weeks, Disruptive Women and guest bloggers, all experts in their respective field–each representing a different perspective — patient, physician, nurse, pharmacist, researcher, behaviorist, policy analyst, distributor, to name a few–will share their analyses, opinions, and solutions.

At the completion of this series, we will compile an e-book as we did when we tackled the issue of Comparative Effectiveness Research.

THE SCOPE OF THE PROBLEM

A new report, Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease, issued by the New England Healthcare Institute (NEHI) found that patients who do not take their medications as prescribed pay a price in poorer health, more frequent hospitalizations and a higher risk of death.

Collectively, noncompliant patients incur up to $290 billion annually in increased medical costs–that’s $290 billion in avoidable medical spending every year, according to the NEHI report.

This is not a new problem, nor is it unique to the US.  In 2003, the World Health Organization (WHO) issued a landmark report entitled Adherence to Long-Term Therapies in which it noted:

Adherence to therapies is a primary determinant of treatment success. Poor adherence attenuates optimum clinical benefits and therefore reduces the overall effectiveness of health systems.

“Medicines will not work if you do not take them.”  Medicines will not be effective if patients do not follow prescribed treatment, yet in developed countries only 50% of patients who suffer from chronic diseases adhere to treatment recommendations. In developing countries, when taken together with poor access to health care, lack of appropriate diagnosis and limited access to medicines, poor adherence is threatening to render futile any effort to tackle chronic conditions, such as diabetes, depression and HIV/AIDS.
This report is based on an exhaustive review of the published literature on the definitions, measurements, epidemiology, economics and interventions applied to nine chronic conditions and their risk factors. These are asthma, cancer (palliative care), depression, diabetes, epilepsy, HIV/AIDS, hypertension, tobacco smoking and tuberculosis.

In the intervening years since the WHO issued its report, adherence has become more problematic.  Numerous reports highlight the ongoing challenges, which are especially critical in the mental health arena.

A study in the American Journal of Psychiatry found that close to 60% of schizophrenics who were prescribed anti-psychotic drugs did not take the medication as prescribed by their physicians.  “We looked at adherence to anti-psychotic medication because they form the backbone of treatment for schizophrenics,” said Dr. Dilip Jesete, co-author of the study.  “These medications are good, but only work when taken properly.”

The study found that psychiatric hospitalizations were higher for people who did not take their medication as prescribed.

When schizophrenics, a disease which affects over 2 million Americans, do not take their medication, they are at risk for dying by suicide.  Four out of ten people who suffer from schizophrenia attempt suicide and one in ten die by suicide.

SOLUTIONS

Despite the complexity of adherence related challenges, a number of promising solutions, innovative responses and well-researched efforts are underway.  Many of these will be described in greater detail in our Drug Adherence series.

Some of these include:

• Text message alerts to remind patients
• Greater use of health care teams
• Integration of health information technology
• Creation of online and offline medication management systems, reminders
• Health e-games
• Insurance reforms
• Public awareness campaigns
• Patient education
• Mobile phone applications
• Research in gender-based barriers

We look forward to your comments and input as we shed light on this critical policy issue.

As politicians battle it out across party lines, there’s an important base of constituents that are taking a lot of the hits: women. In fact, “it’s becoming obvious that just having a female reproductive system is a pre-existing condition in the healthcare debate,” writes Wisconsin-based reporter Ellen Goodman.

Goodman is referring to several issues that have recently come to light, such as tighter restrictions on abortion (a measure that was recently defeated in the Senate Finance Committee), or the debate over comprehensive maternal care. Indeed, the Kaiser Family Foundation reports that only 18 states have a requirement for such coverage, (the number falls to 14 when applied to individual insurance markets) while the numbers of plans without or adding expensive policy riders continues to rise.

However, it gets worse. If a woman purchases a policy after she becomes pregnant, the fetus is often considered a “pre-existing” condition, thereby excluding provision of care. The rationale? Pregnancy is “optional.” More appalling is the fact that many insurers consider having had a C-section an equally compelling reason to deny coverage, or to flag charts so that the ability to purchase a policy elsewhere becomes almost impossible.

Are our reproductive systems the only thing under attack? Unfortunately, the answer is no. The gender bias extends far beyond the aisle and into the realm of what is supposed to be a safe haven: the home. In the District of Columbia and eight other states (Idaho, Mississippi, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming), having a history of domestic violence is also considered a pre-existing condition, and has been used as a factor when deciding whether or not to provide or extend coverage. Here, insurers have claimed that battered women are more prone to having medical or psychiatric issues that will raise costs. In these cases, these women are victimized not once, but twice: first by their abusers and then by insurers who are unwilling to take the risk.

So, what’s the answer? If you believe the argument of Arizona Senator Jon Kyl, who, speaking directly about maternity care stated that “I don’t need maternity care and so requiring that to be in my insurance policy is something that I don’t need and will make the policy more expensive,” then you are sitting on the wrong side of the aisle. This isn’t a reproductive issue; it’s a human one.

Ever wonder why your physician only spends 5-10 rushed minutes with you during your office visit? You may think it’s because there are simply too many patients vying for her time, but that’s not the real reason. The root cause is that health insurance companies are stealing time from your visit by requiring excessive documentation from your doctor. She can’t give you the time you need, because doing so would put her out of business.

In a special report on the administrative burden of healthcare, MedPage Today revealed that PCPs spend about one third of their income on documentation required by health insurers. Because they run a business with thin margins, they must increase the volume of patients they treat in order to cover the salaries of the staff required to manage this “paper weight.”

About 49% of all physicians have said that they are considering retiring or quitting medicine in the next two years (the rate is lower for specialists), largely because of increasing documentation requirements and decreasing reimbursement.

Primary care is hardest hit by costs of coding and billing requirements, since they charge relatively little for their individual services. Imagine the difference in complexity between freezing a wart versus removing an appendix. Yet the number of people required to document, code, and process the paperwork for those two procedures are similar. The reimbursement, however, can differ by thousands of dollars.

The average PCP requires 4.5 staff to manage the administrative challenges associated with practicing medicine. If you consider that the average annual income for a PCP is $149,200, then it’s easy to see why a PCP’s income barely covers staff salaries, let alone the overhead associated with office space, supplies, and computer technology.

How can family physicians survive in this hostile reimbursement environment? There are really only two choices: to work in large group practices or to cease accepting insurance. (Of course, I’m leaving out the third option: to choose a different career).

I have decided to join an insurance-free practice. Now, before you assume that this means “concierge medicine” with exorbitant membership fees – let me tell you that it’s not what you think. DocTalker Family Medicine simply charges an hourly rate for my time – and I do whatever is appropriate for the patient, whether it’s a house call, an office visit, an email, or a phone call. There is no membership fee, people can pay with their credit card, cash, check or PayPal, and once we’ve met in-person and a full history and physical is performed, much of their care can be accomplished remotely.

So what does that cost? The average patient in our practice spends $25/month on their primary care needs. Isn’t that amazing? We can charge reasonable rates because we’ve reduced office staff from 4.5 to 0.5 people/provider and we pass on the savings to patients. We answer our own phones, we see almost all patients within 24 hours, and we’re available 24/7 by phone and email. And you know what? We’re happy to do it because we find meaning in every interaction. We aren’t being crushed by a paper weight.

As healthcare reform moves forward, and new ways are sought to wring money out of a crazy and convoluted system, it might just make sense for some of us to opt out and get back to basics: a doctor or nurse available 24/7 for your primary care needs at a price you can afford. No red tape, no unnecessary office visits, no insurance company hassles.

Anderson Cooper sent a reporter to our practice to see for herself what hassle-free medicine actually looks like. I hope you enjoy the segment… and if you’re in the DC or Virginia area, please check us out for yourself!

This post was originally published at Better Health.

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.

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.

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.

In the midst of furious showdowns on health care reform at town hall meetings, a moment of peace surfaced in Montana when President Obama drew bipartisan applause after calling a mother heroic.  This mother of two had voiced her concern about the Medicaid program she relied on for her child who has multiple chronic conditions.  The president reassured her and went on to discuss how our disease-care system does not proactively manage chronic conditions.

Children and young adults with chronic medical conditions and disabilities (CMCD) need proactive management now and for their entire lives.  Our health care system fails to serve the young people who need it the most.

Children with CMCD are completely dependent on adults for their health care.  Poor health management negatively affects their growth and development, education, and socialization – and drags the entire family down.  As the mother of a young adult with CMCD and the founder of a non-profit created because of our experiences with poor quality health care, I cannot understand why this population is not a major focus of health care reform.

One path to start on is to build on successful programs to create a comprehensive system of care.  Take a look at the 35% of children with CMCD covered by SCHIP/Medicaid. Medicaid provides a specialized set of comprehensive services known as EPSDT, Early Periodic Screening, Diagnosis, and Treatment Program. The current model of care in favor for chronic conditions is the medical home. First conceptualized by the American Academy of Pediatrics for children with CMCD in the 1960s, the medical home has yet to become the standard of care for children with CMCD in Medicaid.  Pairing EPSDT with the medical home would be a step forward in developing a system of care for children covered by Medicaid.    Another step is to expand EPSDT and medical homes to cover the remaining publicly covered children with CMCD enrolled in SCHIP.

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