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!

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…

Most people are dissatisfied with the U.S. health system overall, with 27% of U.S. adults rating the system as “poor” and 29% giving a rating of “fair.”

High costs may be at the root of peoples’ dissatisfaction with the U.S. health system. Only 18% of people are satisfied with the cost of health insurance; only 15% satisfied with the cost of health services not covered by insurance.

EBRI looked into peoples’ health-consumer behaviors, detailed in the chart. Most people who have visited doctors ask them to explain why a test is needed, as well as inquire about risks of treatments and medications and their success rates. Nearly one-half of people ask about less costly treatment options often or always.

Consumers also adjust their health care utilization when facing higher health care costs:

• 74% of U.S. adults try to take better care of themselves
• 69% choose generic drugs when available
• 64% talk to the doctor more carefully about treatment options and costs
• 59% go to the doctor only for more serious conditions or symptoms
• 44% delay going to the doctor
• 36% switch to over-the-counter (OTC) drugs
• 34% look for cheaper health insurance
• 31% look for cheaper health providers
• 25% skip medication doses or don’t fill prescriptions.

Health care costs are eating into peoples’ savings contributions: 56% of people say they have decreased contributions to other savings due to health cost increases, and 33% have difficulty paying for other bills beyond health care.

The Health Confidence Survey interviewed 1,001 U.S. adults over age 21 in May and June 2011 via telephone.

Health Populi’s Hot Points: The future of health care in the U.S. feels very uncertain to the nation’s health citizens: “confidence about the health care system decreases as Americans look to the future,” EBRI found. 57% of Americans say they’re confident about their ability to get treatment they need today. However, only 30% of people are confident they’ll be able to get needed treatment over the next 10 years. Only 20% are confident they’ll get necessary treatment when they’re eligible for Medicare.

In the immediate term, with health consumers concerned about costs, they’re responding by seeking information about their providers, treatments and costs, shown in the second chart. While “all” of the information people seek about health care isn’t available for any of the types of information sought, most people are finding “some” of the information they seek. The most popular kind of information sought is comparing treatments’ disadvantages and advantages, sought by 54% of U.S. adult. However, only 1 in 4 people found all of the information they sought on comparisons. 31% of people look for the full costs of different treatments: only 23% of people found all of this information.

Consumer empowerment requires information transparency. As health citizens in the U.S. continue to take on more financial responsibility for health, they appear to be trying to take that role of health “consumer” seriously. To do that requires information that’s available in accessible, understandable forms via media channels and platforms people want to use. While there’s a proliferation of these services emerging – Castlight Health, Change:healthcare, and QuickenHealth, among them — most health consumers aren’t aware of or accessing these services yet.

It’s a long, winding and bumpy ride on the road to consumers’ empowerment in health. It will get bumpier without health plan sponsors’ linking their enrollees to services that will truly empower them to make sound decisions on how to use the health system.

Originally posted on Health Populi on October 10th.

But there was another line in the blockbuster movie that moved me even more. I heard it and the heavens seemed to open. The light bulb came on.

Hilly Holbrook’s new maid is $75 short on one of the college tuitions for her twin sons and asks Hilly and her husband for a loan so she doesn’t have to choose which son should go to college. Doing the ‘Christian thing,’ Hilly refuses, “God does not give charity to those who are well and able.”

Twelve simple words from a fictional 1960’s character summed up our nation’s current political will regarding the poor. And allow me to condense this into just one word: selfishness.

We movie-goers were quick to see the bigotry in Hilly’s statement. The maid and her husband had been saving money from their meager wages for a long time and she wasn’t seeking a hand-out, but a loan she would pay off with her thankless labor. But I was also quick to see the hipocracy in those of us who identify ourselves as Christians regarding the poor–many like this maid are in temporarily tight spots by no fault of their own. I was convicted by the thought that a selfish Christian is just as much of an oxymoron as a Christian murderer.

We use the word Christian so loosely nowadays, especially in politics. Calling ourselves Christians is not just the politically sexy thing to do. It is bearing the responsibility to personify the totality of God’s word and value every stage of every life, even the poor. Perhaps our selfishness is rooted in fear, more specifically, fear of shortage. We are so afraid that assistance to the poor robs us, but the Bible is clear that it is better to give than to receive (Acts 20:35) and we will never lack giving to the poor (Proverbs 28:27). Now I’m not suggesting that Christians are obligated to give to any and everybody. We must be good stewards over what we’ve been blessed with and use wisdom, but we must never forget we have been blessed with what we are stewards over. None of it truly belongs to us.

What makes giving complicated is when the poor is undeserving for reasons we determine in our own minds. With the issue of Medicaid, for example, we are quick to point to the rare cases of system defrauders. But for every story of fraud, there are at least nine stories of genuine need.

The Institute of Medicine, the trusted, non-political council advising the nation on ways to improve health, recently released “The Healthcare Imperative Report” on how to lower health care costs and improve outcomes. The Institute thoroughly studied excess costs in our health care system and identified six domains of excess spending: unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities and fraud. Want to guess how much waste is due to fraud? Less than you think. Only 10 percent. And that figure includes fraud at the hands of payers, clinicians and patients, so patient fraud represents only a fraction of health care waste.

I got ticked off… Oh, pardon me… I was greatly disturbed this week while speaking with a cousin who attends one of Columbia, SC’s most prominent churches. After the August 5-6, SC Mission 2011: Midlands event that served more than 2,000 uninsured from around and outside the state, a water cooler conversation at the church included appalling accounts of some people in line for services using iPhones. The nerve of those beggars!

Thankfully, my cousin was quick and correct to point out that many of those in line were among the working poor. SC Mission 2010 in Greenville, SC, for example, drew 1,200 of the state’s underserved to the Carolina First Center. Forty-four percent were employed, tax-paying citizens. My co-worker even received a call from an area city councilman inquiring if his uninsured family of four (wife, two teenagers and himself) could come for services at the Midlands event at the Carolina Coliseum.

These are realities, but we citizens have made it too easy for our elected officials to turn a blind eye and deaf ear. In an attempt to heighten awareness of these realities to policy-makers, the South Carolina Hospital Association sent personal invitations to Mission 2011 to more than 400 elected officials in federal, state and local government. Guess how many showed up? Two. Republican SC House Representative Todd Atwater who also serves as President of the South Carolina Medical Association and volunteered at Mission, and Democratic SC House Representative Leon Howard. Two, I said! One Republican. One Democrat. Zero from the Tea Party. Zero Independents. Zero from local government. Zero from the federal government. Raise your index finger, then your middle finger. Two. They could have at least followed the lead of Columbia, SC Mayor Steve Benjamin who knew he’d be out of town. Mayor Benjamin marketed the event through e-mail and social media.

Maybe if more of our officials had seen the lines of men, women and children forming as early as 10 am the day before the Midlands event began, those camping on the concrete outside the Carolina Coliseum, and the countless people who were turned away due to maxed capacity, these and other social ills would not plague our community as much because policy-makers would be more prone to do the true ‘Christian thing’ and care.

According to the study published in the journal Health Services Research, 21 percent of American adults said they had delayed care for non-financial reasons compared to 19 percent that cited cost as the primary reason for not seeking healthcare.

Those non-financial reasons included not being able to get to a doctor’s office during working hours, long commutes to the medical office, or not being able to get an appointment soon enough.  As the study’s lead author said, “In reality, there are all kinds of reasons why people can’t get the care they need when they need it.”

There are at least a couple of important points to take from this report.  One is that healthcare providers have to continue exploring creative ways, from telemedicine to non-traditional office hours, to meet the needs of today’s patient population.

More importantly, though, as we’ve said often over the past several months, coverage and access are not synonymous with each other.  The Affordable Care Act makes health coverage available to all Americans, but that doesn’t mean that all of these newly-insured patients will have easy access to quality care.  If some patients today, as the study indicates, have difficulty getting an immediate appointment with a physician, that problem may only worsen when an influx of new patients, the aging of the baby boom generation and a future shortage of healthcare professionals converge.

Although cost may play a role in peoples’ thinking, a comprehensive eye exam costs as little as $45-50 at retail outlets. I suspect that the real reason why people don’t get regular eye exams is because they incorrectly believe that if their vision is stable, their eyes are healthy.

A comprehensive eye exam is a type of medical check up – it is not just a vision assessment. Eye care professionals can diagnose everything from glaucoma and cataracts to high cholesterol, diabetes, high blood pressure, and even neurologic conditions such as brain tumors and multiple sclerosis. The eyes are more than a “window to the soul” but a window to general physical health. And the good news is that exams are relatively inexpensive and painless – so please consider making them part of your yearly health maintenance routine.

And to my primary care friends – don’t forget to encourage your patients to get annual eye exams. As the CDC notes:

Recommendations from primary-care providers can influence patients to receive eye-care services; persons who had visual screening during routine physical examinations had better eye health because of reminders to visit eye specialists. Public health interventions aimed at heightening awareness among both adults aged ≥65 years and health-care providers might increase utilization rates among persons with age-related eye diseases or chronic diseases that affect vision such as diabetes.

I myself have had an unexpected diagnosis during an eye exam, and feel passionate about the importance of preventive screening. In fact, I’ll be the upcoming host of a new eye health education initiative – a radio show called, “Healthy Vision with Dr. Val Jones” supported by ACUVUE brand contact lenses. The first show will be released here today, and it’s also available at Blog Talk Radio.

References:

Reasons for Not Seeking Eye Care Among Adults Aged ≥40 Years with Moderate-to-Severe Visual Impairment — 21 States, 2006–2009. Morbidity & Mortality Weekly Report, May 20, 2011. 60(19);610-613

Alexander RL Jr., Miller NA, Cotch MF, Janiszewski R. Factors that influence the receipt of eye care. Am J Health Behav 2008;32:547–56

Strahlman E, Ford D, Whelton P, Sommer A. Vision screening in a primary care setting. A missed opportunity? Arch Intern Med 1990;150:2159–64

Originally posted on Better Health on July 13th.

• 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.

By Hope Ditto. It’s still too early to tell what exactly will come of the repeal vote on the Hill this week, and what it will mean for health care coverage. Whether the law is repealed altogether, or whether supplemental bills changing different parts of the original legislation are passed, only time will tell. Whether Obama will veto the repeal act, should a repeal make it to his desk (okay, that’s pretty certain, but stranger things have happened), or whether the Republicans would be able to whip enough votes for an override, we can only venture guesses. Only one thing is for certain – there has never been a more confusing time to buy health insurance.

That’s where health care benefits consultants – like Disruptive Women blogger and Golden & Cohen benefits consulting firm co-founder Stephanie Cohen — come in the picture. Cohen is an expert in the field of health insurance and familiar with all of the changes being implemented (no easy feat). Along with the other consultants at her firm, Cohen helps to find the best possible coverage for individuals and groups (insurance world speak for families and companies), taking into account each entity’s specific needs and financial situations.

I recently had the opportunity to sit down with Stephanie and ask her about all things health care – including her tips for choosing a health insurance plan. Here’s what she had to say.

Question (Q): Why does a person or a company seek out a benefits consultant as opposed to just securing their own health insurance?

Stephanie Cohen (SC): A benefits consultant is an expert in health insurance; most people are not. Purchasing a health insurance policy is like preparing your tax returns; what one puts together for his or herself may be very different from the next person based on many variables both known and not known. Only an expert, who understands all the questions to be asked, can determine the appropriate policy that will yield the greatest return. Health insurance matters so much; why would you risk making a bad decision based on your own inexperience?

Q: Obviously when you say health care these days, one topic and only one topic comes to mind – health care reform (and subsequently, recent attempts to repeal it). In what way will the final decision on the Hill regarding repeal impact your work?

SC: Uncertainty begs for good consultation. The more things are in flux, the more consultants are needed.

Q: Speaking of health care reform and the happenings on the Hill of late, how would you explain the pros and cons of the Affordable Care Act to someone less familiar with the health care/health insurance industry?

As with anything, there are pros and cons to the Affordable Care Act, and its repeal. On the one hand, it allows people with pre-existing conditions to get coverage at reasonable (or at least comparable) rates, it allows dependents to stay on their parents’ plan until the age of 26 and it eliminates co-pays on routine physicals. But, it is driving the cost of all insurance up, it is not friendly to business, it won’t bend the cost curve and it is creating a shortage of consultants due to changes in compensation. In the end, it is a matter of weighing the costs and the benefits and accepting that there is still work to be done.

Q: And maybe you will be one of the people working on that, given your role as a member of the DC Insurance Commission. How did you get involved in the DC Insurance Council and what specific strengths/particular areas of knowledge will you bring?

SC: I joined the DC Insurance Council in order to make sure that broker/consultant values were understood and acknowledged by those involved in the council. My job is to understand the entire system and all of its parts. In that regard, I can bring to life the real experiences, needs and shortfalls in the system as it pertains to the many parts involved in the delivery and cost to the consumer. I can also give factual information that will derail many of the misnomers that others may base their opinions on because I am so familiar with the insurance field.

Q: Okay Stephanie, just one last question (any more and we would have to ask your consulting fee!) — what would you say are the most important things that people should look for when selecting insurance plans?

SC: Remember that cost is only one factor. You have to understand your own health care needs and then pick a plan that addresses those needs, keeping in mind too your potential future needs. Things like deductibles, co-insurance, drug benefits and provider networks should all play a big part in plan selection.

We may not know what is in store for the Affordable Care Act, the Repealing The Job-Killing Health Care Law Act (which at least one Republican senator promised would get its day in the Senate soon) or any of other pieces of legislation which are certain to surface over the next few weeks, but we – or at least Cohen – knows what people need to do to find the best coverage for their situation now – whatever legislation is or is not in effect when “now” arrives.

So grab some popcorn (or one more little slice of pumpkin pie), cuddle up by the fire with your laptop and click away at the links below!

In the States: The Future of Health Insurance

In the Trenches: Who Will Buy What From Whom

For those of you who missed our previous post about our Health Reform After the 2010 Election event, you can read it and watch the first video segment here.

Happy Thanksgiving from all of us Disruptive Women!

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.

Debates continue about the impact of health reform on small businesses. Mine is a small business so I’ve been paying close attention. I’ve even read every line of this legislation – three times. And every pundit analysis I can get my hands on.

My role as a strategist requires that I understand the law. My role as a business owner requires that as well. Most analyses make broad-brush statements and it’s not possible to know the full impact until each business does its own analysis. Here’s mine.

Unfortunately, there are no ‘upsides’ for my employees or business:

• My company is too small to be required to provide health insurance. That’s of no matter, I’ve been providing it all along.
• My company is unlikely to grow to the size required to provide health insurance. That’s of no matter, I’d do it anyway. As an employer I know the value of a healthy workforce.
• My company is too busy to even consider applying for grant funds for worksite health promotion and disease prevention. We’d lose productive work hours watching for RFPs, framing proposals and even more complying with paperwork. That’s of no matter, I’ve been providing that all along as well.
• My company is composed of workers too highly compensated to qualify for insurance tax credits, and I suspect no company like mine will qualify either. My employees are knowledge workers with advanced degrees and compensation above the $50,000 annual ceiling for the tax credit provisions.

Unfortunately  there are ‘downsides’ for my business, all related to new IRS rules.

Section 9006 mandates that about 18 months from now, my business – which really means my Executive Assistant, who is already plenty overloaded – will be required to issue 1099 tax forms to any individual or company from which we buy more than $600 in goods and services.   

We already issue an IRS Form 1099 to people like freelancers who are not ‘incorporated’ business entities. In any given year, that number ranges from 10-14.

That means we don’t send a 1099 to other incorporated businesses, that is, to Amazon, Amtrak, US Airways, Continental Airways, British Airways, Air France, Westin Hotels, Marriott Hotels, Holiday Inns, Kinko’s, Federal Express, Staples, Office Supply, Office Doctor, IT Edge, Samsung, Independence Blue Cross…I could go on.  

This new 1099 reporting is intended to capture currently unreported income to generate more government revenue and help offset the cost of reform. It’s been defended as an alternative to raising taxes on small business and is seen to be a fair trade for $35 billion in tax credits small businesses get under reform. It’s an attempt to collect the nearly $300 billion of income that the IRS says goes unreported.

I have three problems with that:

• First, my business won’t see any of that tax credit benefit, 
• Second, my business will incur additional costs, not only in staff time for obtaining tax IDs from every vendor, but also in accountant fees for processing and mailing the forms, and
• Third, my business is being required to help the IRS monitor tax reporting compliance of other businesses.

At this point, we estimate the number of 1099s we will file will increase to 1,000. I’m not sure how a small firm like mine is going to find its way through the mazes of large companies to get the information, but I’m angry that this law – touted as having so many ‘upsides’ – provides none for my firm but asks us to carry an additional burden that drives up the cost of doing business.

I can live without the ‘upsides.’ I’ve provided insurance and promoted wellness all along and will continue to do so.

But now, I’ve been mandated to become a de facto agent of IRS enforcement. Surely, the IRS has better tools for finding unreported income than asking small firms like mine to do it for them.

According to the CDC, nearly 50% of the U.S. population suffers from a preventable chronic health condition, and these diseases account for 75% of the nation’s $2 trillion annual healthcare costs. Much of these costs arise from:  patients obtaining care from multiple healthcare providers, lack of medical care coordination, duplicate diagnostic testing and provider visits, and treatment non-compliance due to consumer confusion.  These facts indicate that increased spending on chronic conditions does not necessarily result in better health outcomes and means that patients with chronic conditions currently receive health care in a manner that may not be the most cost-effective.  These statistics are even more pronounced for minority adults and children as well as for those with low incomes, for whom there are greater disparities in access to care and treatment plan compliance.

That’s why I was glad to hear that H.R. 3590 Patient Protection and Affordable Care Act had provisions related to the patient centered medical home (PCMH) model of care.   According to the Patient Centered Primary Care Collaborative, PCMH is an approach to providing comprehensive primary care to adults, youth and children that broaden access to primary care while enhancing care coordination. Clinicians practicing in the highest level medical home will:

• Take personal responsibility and accountability for the ongoing care of patients
• Be accessible to their patients on short notice for expanded hours and open scheduling
• Be able to conduct consultations through email and telephone
• Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records
• Conduct regular check-ups with patients to identify looming health crises, and initiate treatment/prevention measures before costly, last-minute emergency  procedures are required
• Advise patients on preventative care based on environmental and genetic risk factors they face
• Help patients make healthy lifestyle decisions
• Coordinate care, when needed, making sure procedures are relevant, necessary and performed efficiently

But isn’t this what providers strive to do already?  Sure is, but there hasn’t necessarily been a systematic provider reimbursement structure to match these goals.  However, if we change the structure it’s a win-win for everyone.  PCMH demonstrations across the country have realized:

• Better health outcomes
• Enhanced patient and provider satisfaction
• Reduced costs

And at the end of the day, aren’t these 3 goals what health reform is really all about?

Watching the unfolding drama of the health care insurance reform legislative process and the citizen responses, I kept looking for the young people. They were virtually invisible, perhaps busy serving food, and their unique plight went unexplored by virtually everyone. I wondered if their concerns were embedded in the endless polls, or even if they were being polled. The mandate for individual coverage, it is anticipated, will uniquely burden these young people. The anticipated challenge of a rapidly expanding aging population with extensive health care needs is their responsibility to assume, we assume.

As a group that has been fairly well researched, the baby boomers have some descriptors they do not like, no matter what the evidence. Along with a whole raft of wonderful qualities, it is often noted that they are self-centered and self-absorbed. They tend to reject this descriptor out of hand. Their elders, in the early studies on generational characteristics, were interestingly not called the “greatest generation” but the “entitlement generation”.  I watched Tom Brokaw’s recent report on the boomers, waiting for him to ask a young person what he or she thought about the boomers. It did not happen. I watched the obsessive air time given to angry, often vitriolic people reacting to the impending health care legislation: none of them looked very young to me.

As a country, we are in a balancing act, weighing the impact of extended longevity against the needs of a larger number of generations. We have four generations in our work force, not two or three, as has been our history. Climbing the employment ladder has gotten a lot more difficult and a lot more complex. Our shared economic crisis has eroded the retirement funds of many, requiring baby boomers to stay on the job longer than planned. We know this because it is given a substantial amount of media coverage.  Even the extended insurance coverage of young people is presented through the eyes of their parents.

I try to imagine what it must be like to be a young adult watching all this unfold. It is their future, of course, not mine. I wonder what they think about the deficit that makes so many people anxious about providing care for our sick and suffering, the lament about the cost of health care increasing our deficit when deficit expanding decisions over the past ten years were often made capriciously.

I wonder what it feels like to be told that the time when your career should be taking off, it just isn’t going to happen but – not to worry – you can stay on your parents’ health care insurance policy. I wonder what they think about extending their dependence on their parents several years, when normal development calls for independence. I wonder what they think of the “grown ups”. As one young adult wistfully said to me about these “grown ups”, “I just wonder when they are going to go away.”

One of the signature anthems of the boomers in their youth was “The Times They Are A-Changin’”. Boomers took over in their youth; they outnumbered the “grown ups”, and they are still in charge. Interestingly, an anthem by John Mayer for emerging generations has a somewhat different title: “Waiting for the World to Change”.  They are not in charge and they know it. They are waiting.

I can see why a lot of aging folks are worried about “death panels”, and why they imagine that this threat exists. I wonder if any of them worry about the emerging generations, who are not being permitted to “start” their adulthood, who quite literally, are wait-persons.

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.

Congressional leaders are outraged that insurers are trying to wriggle out of their legal responsibility to insure new children who have pre-existing conditions. 

1. Insurers are interpreting bill language to mandate coverage of pre-existing conditions of children only if they are currently enrolled in plans, but not for new, uninsured child customers with pre-existing conditions. 
2.  The administration vows to fix this by having Health and Human Services (HHS) issue regulations next month to clarify the law’s intent to both provide access to insurance and a full range of benefits for all children with chronic conditions this year. 
3. Insurers plan to act on legislation language.  They will not say how they will respond to regulations and forecast that the courts will be the final arbiters.
4.  HHS spokesman and chairmen of Congressional health policy committees in the House of Representatives assert that the administration’s solution adequately addresses this problem.  
5. Citing experiences in other states, insurers are saying that covering children with chronic conditions now will lead to higher rates that may be unaffordable.  They believe that it is better to wait until 2014, when the risk can be spread since most Americans will have to be covered that year.
6. Regardless, insurers are free to charge what they want until 2014, when health status can no longer be used to calculate premiums. 

This is no small matter, for one in five American households, 8.8 million, has at least one child with a pre-existing condition.  Contrary to popular thought, most of these children are covered by private insurance.  The economic and job crises have impacted the ability of parents to maintain employer-based health insurance, forcing them to turn to the exorbitant individual market.  Children with individual coverage and who go without insurance for two months are at the greatest risk of being denied access.  From September 2010, the health care bill is supposed to prohibit insurers from denying individual and group coverage to children based on health status.

Health care reform does provide for a $5 billion dollar insurance pool of last resort that these families can turn to.   Hopefully, this mechanism will help families until this problem is straightened out.

Parents cannot wait to obtain coverage for their children who are in urgent of need of health care now.   Children are not simply little adults:  denying access and care to chronically ill children denies them the ability to grow, develop, play and learn.  As we watch the deliberations and wait for implementation of this piece of law, our children and families are losing precious time that can never be recovered.