In a grassland wildfire, when the fire is spreading so quickly that there’s no way to run away from it, there’s one last solution to save yourself: an escape fire. In this technique, you light a ring of fire around you, using up the fuel that is feeding the wildfire so that it has nothing to burn when it reaches you. The problem is, when you’re running for your life, the most effective solution is also the least obvious – stopping in your tracks to light a fire is the last thing a panicked person would think to do. You could die from your inability to face and accept the choice that is right in front of you.

That’s the idea behind the title of the film Escape Fire: The Fight to Rescue American Healthcare. I had a chance to see it this weekend on CNN (it’s available now online and on DVD), and it makes a compelling argument that our current system for dealing with rising health care costs and falling positive health outcomes is akin to running away from a seemingly insurmountable problem when there are solutions right in front of us. In example after example, patients dealing with chronic illness, which is the main driver of skyrocketing health care costs, are dealt with by disease management that does nothing in the way of future prevention. (more…)

The awareness of breast cancer and the companion calls-to-action have truly been amplified during this decade. Recently, in honor of breast cancer awareness, football teams wore pink sneakers, the so-called “real” refs wore pink wrist bands, the well-promoted and participated Susan G. Komen three-day walk ended with the usual enthusiasm and broadcast media attention.

Back in the late nineties, I worked at a corporation that was centered on women’s health. We proactively reached out to organizations associated with women’s health, including Susan G. Komen, and offered to bring our resources to bear to assist in raising awareness and amplifying their messages. In those days the only talk about breast cancer seemed to occur when a teary-eyed friend or co-worker would whisper that she discovered a lump. So it is all wonderful that this health issue and the call to get mammograms have reached the population at large such that even teenage boys drive cars with pink ribbons on them. However, all of this awareness masks some serious issues. (more…)

In May 1999, Abigail Sulerzyski was born deaf and blind with cerebral palsy and multiple other medical complications. While Victoria, her mother, was learning how to cope with the needs of a severely disabled child, she was also learning how to fight with UnitedHealthcare.

Abigail required continuous feeding through a jejunostomy tube, and the insurer was denying the prescription nutritional supplements that Abigail needed to survive. As Victoria was preparing to mount a legal battle against United, “something changed around December of that year,” she said. The formula along with other specialized equipment was covered.

“I went from having to fight for everything to having their nurse call me every month to ask, ‘How can I help you?’” Victoria didn’t bother trying to understand this abrupt change; she was just grateful to have more time to take care of her daughter. (more…)

The Eating Disorders Coalition for Research, Policy & Action (EDC) is a non-profit organization working to advance the federal recognition of eating disorders as a public health priority.  Through education, lobbying and advocacy efforts we promote policies that address the problems faced by people with eating disorders, and that may prevent further people from developing eating disorders. We are a coalition of more than 35 organizations in the eating disorders education, prevention and treatment communities and represent millions of people impacted by eating disorders and their families, providers, researchers and advocates.  In this article we highlight two efforts currently underway. (more…)

By Mary Grealy. Today, I saw an argument in support of the Independent Payment Advisory Board (IPAB) – the 15-member board of political appointees with unprecedented power to reduce Medicare expenditures – that was so off the mark one would think it came from some sort of fringe website.  In fact, it was found on CBS News’s Marketwatch site.

CBS provided webspace for a consulting actuary to argue that there is really no difference between IPAB and private insurers.  IPAB will, he said, “assess whether certain procedures will be denied reimbursement, either due to ineffectiveness or excessive costs,” the same as private health insurers.  IPAB members may be unelected, but, he argues, private insurance claims adjusters aren’t elected either.

“It’s just a reality that any insurance program, whether commercial or governmental, will deny some claims, states this CBS News-hosted editorial.

We won’t even get into some of the obvious differences between IPAB and private coverage, such as the fact that employers can take their business to different insurers.  Or the fact that private insurers have appeals mechanisms, whereas IPAB decisions aren’t even subject to judicial review.

But that’s not even the biggest problem with this pro-IPAB argument.  IPAB isn’t structured to cut costs by denied payment for ineffective procedures.  It’s not about that at all.

As the Congressional Budget Office has made quite clear, the law creating IPAB explicitly forbids the board from rationing care, changing Medicare benefits or increasing beneficiary cost-sharing.  According to CBO, the board will, for all practical purposes, be limited to cutting healthcare provider payments to meet its cost-cutting targets. (more…)

By Mary Grealy. While the U.S. Supreme Court was hearing oral arguments this week on the constitutionality of the individual mandate provisions of the Affordable Care Act, another serious concern about the mandate didn’t involve constitutional issues and stayed relatively unnoticed.

Is the individual mandate sufficient to achieve its intended goal, to bring healthy Americans into the health insurance pool?  In answering this question, the stakes are high.  If millions of currently uninsured Americans choose to remain without coverage, and simply pay the noncompliance penalty instead, serious questions are raised as to whether other insurance reforms can take effect – most importantly, eliminating pre-existing conditions as a barrier to coverage – without destabilizing the marketplace.

This is a legitimate worry.  In 2014, a person who chooses to remain uninsured would be penalized $95 or one percent of adjusted taxable income, whichever is greater.  And even when the penalty is fully implemented in 2016, the penalty will be the greater amount of $695 or 2.5 percent of adjusted taxable income.  These penalties will still be less than the cost of purchasing health coverage.

As University of Illinois law professor Richard L. Kaplan put it, accurately, “(A) person might choose not to buy health insurance, opting to wait until something medically unfortunate happens.  Insurance companies will not be able to refuse her at that point, a situation that might imperil the private insurance market.”

Even if the Court upholds the constitutionality of the individual mandate, lawmakers can’t complacently assume that it will be strong enough to move uninsured citizens into the insurance marketplace.  It would be worth studying the efficacy of other incentive programs, such as those used by the Medicare Part D prescription drug program.  Part D has utilized both limited enrollment windows as well as higher costs for those who delay enrollment.

The goal of incentivizing Americans to acquire health insurance is a good and necessary one.  It’s necessary, though, to keep in mind that the constitutionality of the individual mandate may be the most visible issue, but it’s far from the only one.

The post above ran first on the Prognosis Blog on March 30th.

My mama told me you’d better shop around, as Smokey Robinson also told us. We now know it pays to shop the prices for digital imaging. The price of an MRI of the brain ranges from a low of $825 to a high of $3,600 within the Southeast region of the U.S. In the Northeast, the low is $1,540 and the high, $3,500. There are similar price “spreads” in other regions of the country for the same imaging study, and across other imaging modalities such as PET and CT.

The greatest regional variances by service type are for MRI scans of the brain, varying 747% between a low price of $425 in the Southwest to a high of $3,600 in the Southeast, based on an analysis from change: healthcare‘s Q2 2011 Healthcare Transparency Index.

USA Today reported on this study on June 30, 2011. Christopher Parks, founder of change:healthcare, pointed out that it’s not uncommon to find inter-regional differences of health prices. However, this is happening ”within a 20-mile radius in your own town,” Parks points out based on his firm’s research.

change:healthcare launched the Healthcare Transparency Index (HCTI) in Q4 2010 to analyze health claims data for various health care services and provide health care buyers with data about cost trends. The tool helps people identify savings opportunities for various health care products and services such as prescription drugs, dentistry, physician office visits, physical therapy, and imaging.

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By Lynn Shapiro Snyder. Reproduced with permission from BNA’s Health Care Policy Report, 18 HCPR 680 (May 3, 2010). Copyright 2010 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com

Health reform is a process, not an outcome. The health care industry needs to treat Phase II of health reform—–implementation by the Executive Branch—with the same focus and zeal as they did with Phase I—deliberation and passage by the Legislative Branch. It may not be as sexy as Capitol Hill but industry participation in shaping implementation through the Executive Branch could have an even greater impact for industry efforts. Phase II is when the rubber of ‘‘the law’’ meets the road of ‘‘the real world.’’ We are one month into implementation so now is the time for the health care industry to step up to the plate and continue to shape the details of federal health reform currently being developed and implemented by the Executive Branch.

As with any topic of public policy, proposed laws are discussed in Congress. Final laws are sent to the Executive Branch for interpretation and rulemaking within something called ‘‘congressional intent.’’ Public comments hopefully are considered by the relevant agencies writing the regulations. Challenges to the regulatory process may occur when the regulations go too far from the words and intent of the statute. Eventually, issues may be sent back to Congress to amend the law. The federal Medicare program has worked this way for over 43 years.

However, in the implementation of federal health reform, we are seeing new creative elements to the implementation process. The Obama administration is asking industry to take steps that are not in the statute. For example, on April 19 Department of Health and Human Services Secretary Kathleen Sebelius sent letters to health insurance companies asking them to continue to cover young adults so that they can remain on their parents’ policies notwithstanding the terms of the policies (18 HCPR 604, 4/26/10). This health reform provision does not take effect until Sept. 23, 2010. She was seeking
collaboration with industry on a topic that could make sense for all involved.

Sebelius also recently sent a letter to the health insurance industry trade group, America’s Health Insurance Plans, challenging the group’s interpretation of a section of the statute related to the coverage for children with pre-existing health conditions even before any regulations were published (18 HCPR 469, 4/5/10). The statute appears to nullify pre-existing illness exclusion contractual provisions for enrolled children later this year but there was a question whether guaranteed issue of health insurance for these and other children had to wait until after 2013. Nevertheless, the administration obtained a promise from private health insurers for guaranteed issue this year for this particular population notwithstanding what some believe are the words in the statute.

Successful implementation of the 2000+ pages of the federal health reform law requires collaboration between the Executive Branch and the health care industry stakeholders. This is because the law is based upon actions to be taken by key health care industry stakeholders, such as health insurers to increase access, and health care providers to achieve Medicare savings.

And since we never had a federal department of health insurance before this new law—health insurance had been regulated mostly at the state level—the Executive Branch’s need for continuous public input and collaboration with industry is even more compelling. The same is true for some of the creative new pilot programs designed to customize the Medicare payments for certain providers.

A big part of implementation is in the Executive Branch’s federal rulemaking activities. That is when the public has the formal opportunity to collaborate with the administration on federal health reform. Not all provisions in the recently enacted Patient Protection and Affordable Care Act (Pub. L. No. 111-148) and its companion, the Health Care and Education Reconciliation Act (Pub. L. No. 111-152), require a federal regulation. Some provisions are self-executing while others specifically require a designated federal official to publish regulations on a particular topic. For other provisions, it depends.

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By Lisa Korin. The media has given much attention to the health insurance aspects of health reform, but less to aspects of the law addressing the root issues.  Yes, the number of uninsured is a huge problem, but let’s not forget that an increasingly chronically ill population needing access to often expensive health services is one the key drivers contributing to the plight of the uninsured even needing insurance.

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: (more…)

By Phyllis Kritek. When I hear a story repeated in different parts of the country by persons who differ, one from another, in striking ways, I pay attention: This is no longer a story, it is a pattern. The stories preoccupying me these days are ones where parents of recent college graduates tell me that their son or daughter successfully completed college but was unable to find a job, and thus became a waitperson, the politically correct term for one who serves food in a restaurant. Usually waitpersons do not have health care coverage through their employer.  We can find these same young people in the health care insurance reform legislation: they can now stay covered by their parents’ insurance policies until the age of 26. I think this is supposed to be good news.

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.

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By Santi Bhagat, MD, MPH. Health Care Reform is off to a good start.  A couple of days ago, I blogged on the debate between the insurance industry and the administration about the interpretation of this new law.  Hats off to insurers for making the right choice, right away, to heed regulations that are forthcoming from Health and Human Services.   I first heard this through the grapevine at the Disruptive Women Breakfast Series this week from Stephanie Cohen, the expert panelist representing the insurance industry.

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.

With the enactment of comprehensive health reform, the Kaiser Family Foundation has prepared a timeline detailing when specific provisions of the legislation are scheduled to take effect.  The implementation timeline reflects the provisions of the Patient Protection and Affordable Care Act, which President Obama signed on March 23, 2010, as well as provisions in the Health Care & Education Reconciliation Act passed by the House and Senate.  It includes more than a dozen key provisions scheduled to take effect in 2010, including the creation of a national high-risk pool for people with pre-existing conditions that can’t buy insurance on their own, tax credits for small businesses that obtain health coverage for their workers and assistance for Medicare beneficiaries with high drug costs who get hit by the drug benefit’s coverage gap or “doughnut hole,” and continues through 2014, when the major reforms to expand access to health coverage are fully implemented. Printable Timeline (.pdf)   (more…)

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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The following post originally appeared on The White House Blog. The Disruptive Women in Health Care blog encourages its readers to take part in the live video chat described below, which will take place today at 3:40 EST.

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The President has now laid out a path forward for health reform that  puts families and businesses in control of their own health care, reduces costs and the deficit, and incorporates new Republican ideas while still instituting fundamental protections again insurance company abuses.  He opened his remarks saying, “I want to especially recognize two people who have been working tirelessly on that — on this effort, my Secretary of Health and Human Services, Kathleen Sebelius — as well as our quarterback for health reform out of the White House, Nancy-Ann DeParle.”  We’re happy to have both of them in a live video chat at 3:40PM EST to take your questions on the President’s proposal.  Secretary Sebelius will also be meeting with insurance company leaders in the morning to get answers on the alarming premium hikes being ushered in on families across the country and will be able to discuss what she heard from them.

• Watch the discussion at WhiteHouse.gov/live
• Watch and join the chat through Facebook