Health Insurance and You!

When it comes to pharmaceuticals, health insurance companies use lower co-payments to entice customers to choose less expensive, generic drugs over brand name medications. Recently, insurance companies have begun applying the same concept to health providers: rewarding customers who choose the cheapest facilities and locations for a given treatment. Rather than discounts on co-payments, writes Michelle Andrews of Kaiser Health News, the new approach is even more direct, involving cash rewards ranging between $50 and $200 per procedure.

Among the insurance companies trying out this strategy are Anthem Blue Cross and Blue Shield in New Hampshire, Connecticut, and Indiana; and Harvard Pilgrim Health Care in New Hampshire and Massachusetts. Insurers are focusing on specific, common services that vary widely in cost and complexity, such as mammograms, MRIs, hip and knee replacements, and tonsillectomies.

So far, the savings have been substantial for insurers, even after taking the cash rewards into account. It works like this: a patient’s primary care physician refers him or her to another provider for a treatment or procedure. Sometime between the referral and the scheduled treatment, the patient visits the insurance company’s website for a list of low-cost providers in the area. If the referred provider – physician or facility – is not on the list, the patient may ask the doctor to change the referral to one that is. After the low-cost provider submits the claim, the patient receives a check in the mail containing the reward. There is no penalty for patients who decide to stick with the original referral.

Some doctors have worries about this approach, writes Ms. Andrews. A major concern is that the list of low-cost providers does not factor in quality. While providers on the list do have to be licensed and have the appropriate qualifications, some perform better than others or have fewer complications. Particularly for more invasive procedures or surgeries, these differences in quality can be important. Providers also worry that changing referrals can hamper the coordination of a patient’s care.

Readers, what do you think about this approach? Would you choose a cheaper provider for the cost of a new outfit or hotel stay? Would you worry about the impact of such a decision on the quality of your care?

Related blog posts:

• 1/11/2012: A Value-Based Approach to Health Insurance
• 10/28/2011: Predicting the Future of Health Insurance
• 10/3/2011: How High-Deductible Health Plans Lower the Cost of Care

Studies have consistently found that people who lack health insurance coverage are more likely to use the emergency room (ER) for needed health care. Often – particularly for poorer people – this is because they have nowhere else to go.  In other cases, a medical problem that would have been detected and treated through preventive care ends up progressing into an emergency if it is left untreated.

It follows quite naturally that people who have recently lost health insurance are also more likely to visit the ER than they did while they had insurance. What’s less intuitive is the idea that people who have recently gained insurance are also more likely to go to the ER. But, surprising as it may be, that’s the result of a new analysis of data from the National Health Interview Survey, published online on Monday in the Archives of Internal Medicine. The study and its findings were described in an article by John Gever of MedPage Today.

The study compared four groups of people: consumers who had consistent coverage during the past year, those who were consistently uninsured during the past year, those who had become insured during the past year, and those who had become uninsured during the past year. Nearly 80% of participants had been consistently insured, and another 13% were consistently uninsured. The remaining participants were evenly split between the two other groups.

Compared to people who were consistently insured, those who had recently gained coverage were about 32% more likely to visit the ER, and those who had recently lost coverage were about 39% more likely. Interestingly, people who had recently enrolled in Medicaid, rather than a private insurer, had an even bigger chance of an ER visit – about 45% more than people with consistent coverage.

In light of health reform, the study authors note that many Americans will go through health insurance changes in the next few years, and that emergency departments should prepare for a possible increase in patients as the law is fully implemented.

Online health insurance exchanges are one of the most highly anticipated pieces of health reform. The convenience of shopping for health insurance at home and being able to directly compare premiums and plans from different companies has been widely praised. But, even with all that information available, the fact remains that health insurance is a very different product to shop for from, say, clothing or books. It’s complex, not always easy to understand, and making a mistake could have severe financial consequences.

What this means is that shoppers are likely to have questions, and a robust customer service system will be an essential part of a successful exchange. But what features should such a system have? As states work toward building these exchanges, three organizations in Colorado decided to ask that question in a series of focus groups, writes Katie Kerwin McCrimmon of Health Policy Solutions. They found that live help from a knowledgeable but impartial ‘navigator’ was key. Consumers also wanted to be able to search for and filter plans by cost, plan network members, and covered benefits. Finally, they wanted exchanges to be a one-stop shop for all types of insurance, including governmental programs they may be eligible for.

Fortunately, these results align with the most recent federal guidance to states creating their own exchanges, which we blogged about last week. The rules require states to coordinate the online health exchange application with state programs such as Medicaid as much as possible. They also provide states with funding to establish health exchange navigator organizations that will help consumers through the shopping process.

Readers, do you agree with these focus group results? Are there other features that that would make your online health insurance shopping experience better or easier?

Where you live has a huge impact on your health, in a variety of ways. Some areas have more pollution than others, which can affect your lung health. Dense cities and other high-traffic areas tend to encourage walking, which can affect the amount of exercise you get. And of course, where you live determines which doctors, hospitals, clinics, government resources, and other health services you are able to access.

Keeping in mind the importance of location, this week, the Commonwealth Fund released its first-ever Scorecard on Local Health System Performance, a report comparing 306 hospital referral regions across the United States based on the most recent data available. The regions were compared using 43 variables in four overarching categories: access to care, disease prevention and treatment, costs and avoidable use of hospitals, and outcomes. In general, areas in the northern Midwest and Northeast fared best and those in the South and Southeast fared worst, but every area had opportunities for improvement. The Northeast, for example, had higher avoidable costs than other regions.

Other key findings, selected from the report’s executive summary:

• Not enough older adults were receiving the recommended preventive screenings. The proportion who were getting screened ranged from 26% to 59%.
• A significant portion, ranging from 0.4% to 11% depending on location, of nursing home residents were in moderate to severe pain.
• Between 13% and 30% of emergency room visits were unavoidable.
• Infant mortality is still a significant problem in many areas. In the lowest-performing quarter of regions, there were between 9.4 and 14.4 deaths per 1,000 live births.

One might expect wealth to have a major impact on these results, but it wasn’t always a factor. Overall, areas with high poverty tended to have less access to care and higher rates of avoidable problems. But when it came to prevention and treatment quality, many poorer areas scored higher than expected, showing that the details of a local health system can have a positive impact.

And relating to health insurance:

• In all areas, children were more likely to be covered than adults, primarily because of federal and state programs such as Medicaid.
• Perhaps unsurprisingly, Massachusetts has the highest proportion of adults with health insurance, at nearly 95%. In contrast, a few localities in Texas had insurance rates as low as 47%.

“The findings show that local health system performance is linked across all dimensions – with better access to care associated with higher quality and better outcomes. This interconnectedness underscores the need for health insurance, payment, and delivery system reforms to improve care experiences and outcomes, while at the same time slowing cost growth,” conclude the authors in the executive summary.

Ultimately, they say, success at the local level will require strong leadership by communities and health providers, who will need to work together to set goals and find ways to meet them. Policies at the national and state levels are important as well, as they set the backdrop for local-level changes. Readers, in our current, constrained economic climate, what are the first steps for local providers and officials to take to improve their performance? If a local program is found to work well, should it be tested in and expanded to other areas?

When a pharmaceutical company’s patent for a new drug expires, other companies are free to produce a generic version of the same drug. At this point, patients can choose whether to continue to take the original drug or switch to the generic version.

Hoping to keep as many patients as possible on the original version, which is usually more expensive, drug companies often issue coupons that patients can use toward co-payments at their pharmacy. A well-known example is the pharmaceutical company Pfizer, which has offered coupons for the cholesterol-reducing drug Lipitor. However, according to an article by David Sell of the Philadelphia Inquirer, health insurance companies are not told when a coupon is used, and thus pay the same price to the drug company as they would if no coupon was used.

This discourages people who could have switched to a generic from making the change – medically, not everyone may be able to do so – and insurers lose out on potential savings from generics. To make up the loss, insurers must pass the expense on to the consumer in the form of increases to premiums and other health plan costs. Medicare and Medicaid have already banned the use of coupons because in the long term, they make everyone’s health costs go up.

For these reasons, four health insurance plans and a community group say that co-payment coupons for brand-name drugs are illegal, and have sued eight pharmaceutical companies for issuing them. The suit, filed in four federal courts, targets Abbott Laboratories, Amgen Inc., AstraZeneca PLC, Bristol-Myers Squibb Co., GlaxoSmithKline PLC, Merck and Co., Novartis AG, and Pfizer Inc.

Readers, have you ever used a coupon to save on brand-name medication at the pharmacy counter? Weighing the potential effects of those coupons on insurance companies and long-term premium rates against their potential savings for people who use them, do you think they are fair?

As we have written previously, the White House issued a rule earlier this year that employer-sponsored health insurance plans must offer free birth control services for their employees. Since the policy applies to all employers – including many religious hospitals, charities, universities, and other organizations that oppose contraception – it was met with considerable resistance and has been debated on the legislative floor and all over the media during the past few weeks.

In response to that outrage, wrote Kathleen Hunter of Bloomberg, the Obama administration announced a compromise on February 10 that would require insurance companies, rather than religious organizations, to cover contraception for those organizations.

But many were still unsatisfied. And so, Republican Sen. Roy Blunt of Missouri proposed the Respect for Rights of Conscience Act, also known as the Blunt Amendment, which would have allowed employers to opt out of covering contraception for moral reasons. According to an article by David Morgan and Thomas Ferraro of Reuters, the amendment was tacked on to an unrelated transportation bill, and did not explicitly relate to birth control. Rather, its language would allow employers to choose not to cover a variety of benefits, such as prenatal care, childhood vaccines, and cancer screenings.

The Senate voted 51-48 against the amendment yesterday, with votes falling largely along party lines. One Republican, Sen. Olympia Snowe of Maine, voted against the amendment, and three Democrats voted in favor of it.

According to a recent poll by the Kaiser Family Foundation (KFF), described in a blog post by Julie Rovner and Scott Hensley of NPR, the public generally agrees with the Senate’s decision. Overall, 63% of Americans support health insurance coverage of birth control. KFF parsed the votes along age, gender, and political lines, and found that younger adults, women, and Democrats were most likely to support the requirement. According to an article by Laurie Kellman of the Associated Press, another poll by CBS News and the New York Times had similar results, finding 61% of Americans in favor of contraception coverage and 31% opposed.

So, what happens now? The U.S. House will be deciding on its next steps soon, said House Speaker John Boehner at a news conference yesterday, wrote J. Lester Feder of Politico. During the past month, the House has held several hearings on the issue, but no bills have been introduced so far.

Today, California’s Office of the Patient Advocate released its annual report card rating some of the state’s most popular health insurance plans and companies. Included in the report were California’s nine largest HMOs, six largest PPOs, and 212 medical groups.

According to an article and accompanying image by Sandy Kleffman of the Bay Area News Group, the HMOs and PPOs were given one to four stars on several factors, such as how well the quality of care met national standards, customer service, asthma care, and care for other specific health conditions. For insurance plans, ratings were based on member experiences and clinical quality measures. For the medical groups that worked with these insurance plans, ratings were based on patient experiences and clinical quality measures, and were sorted by county.

The results were mixed, writes Ms. Kleffman. For example, the state’s insurance plans have become better at caring for diabetes patients, a change that could be attributed to previous report cards, which identified diabetes care as a problem area. Now, the state’s plans exceed national standards on most diabetes care measures. On average, they have also improved at controlling high blood pressure and cholesterol, writes Chad Terhune of the Los Angeles Times.

OPA hopes for similar improvement in care for more health conditions identified by the report, for which California failed to meet national standards. Among them are flu shots for adults, care for children with ADD, treatment for substance abuse, and testing for lung disease. According to OPA director Sandra Perez, quoted in Mr. Terhune’s piece, releasing the report card data publicly will urge providers to improve their quality of care and health plans to change their policies.

Customer service was also lacking, the report found. All but one of the health plans that were rated scored one or two stars in this category, which included unexpected costs, accuracy of claims, and resolution of complaints.

Readers, how would you rate your insurance plan? What factors do you consider most important?

On this blog, we’ve written often about the differences in health care patterns between people with health insurance and those who are uninsured and underinsured. Some are expected, such as the fact that people without coverage tend to use emergency care more frequently and aren’t able to afford as much preventive care. Others are more surprising, like the recent study that found no association between insurance status and use of walk-in clinics.

Last month, researchers at the American College of Radiology published an article comparing the use of emergency room imaging tests – including x-rays, MRIs, CT scans, and ultrasounds – between people without insurance, people with Medicaid (who some consider underinsured), and people with other insurance. They found that Medicaid patients were about 10% less likely than those with other insurance to receive any imaging, and uninsured patients were about 8% less likely. This pattern was quite consistent across different types of imaging.

The researchers noted that more research needs to be done to determine if people with non-Medicaid insurance were getting unnecessary imaging done, or people with Medicaid or no insurance were not getting enough.

What’s more certain is that the uninsured patients were not getting the care they needed. According to the study results, uninsured patients were less likely to be admitted to the hospital and receive follow-up treatment, and were more likely to leave before being seen and even to die in the emergency department. This agrees with previous studies that found that the uninsured are less likely to get timely health care, which means they are usually sicker when they first arrive at a clinic or hospital. One would expect a sicker patient to need more imaging and other care, but the results show that what’s happening is just the opposite.

Readers, how would you address this issue? If you’ve ever been uninsured (or know someone who has), how has it affected the way you use health care services?

Frequent travelers, do you get nostalgic when thinking about free airline meals and checked-in luggage? In this tough economy, many doctors’ offices are trying an approach similar to the one that airlines and banks started taking a few years ago: charging small fees for services that used to be free.

Bob LaMendola of the South Florida Sun-Sentinel describes the trend in an article that appeared this past Sunday. Among the services that doctors have begun charging for are walk-in care, missing an appointment, getting a copy of your medical records, coordinating treatment with specialists, getting blood drawn, and filling out paperwork. Some patients, Mr. LaMendola writes, are getting annoyed by the fees.

But doctors – especially primary care physicians, whose incomes tend to be lower than those of specialists – are feeling squeezed by their reimbursement rates from private health insurance companies and public programs. Since primary care offices increasingly serve as patients’ medical homes, these doctors and their staffs end up bearing the brunt of those administrative duties. And they’re generally not reimbursed for them (although, as we blogged earlier this month, that is slowly changing. Whether that change will affect this one remains to be seen).

Luckily for patients, who may worry about ever-increasing fees, not all services are fair game for extra charges. For example, explains Mr. LaMendola, Medicare and insurance companies don’t allow doctors to add fees to services that are already covered. If they do, they may be dropped from the plan’s network and so could lose many of their patients.

When imagining health care and the work a doctor does, most people immediately think of office visits, surgeries, and other services where the patient interacts directly and in-person with the physician. That’s how health insurance companies have traditionally thought of it as well. But doctors do a lot of work outside of those activities, such as coordinating care with specialists, paperwork, answering emails and calls from patients who don’t have appointments, and in some cases, holding office visits online after hours. Generally, insurers don’t reimburse them for these duties.

But that’s starting to change. In an article for the Connecticut Mirror, Arielle Levin Becker reports that Anthem Blue Cross and Blue Shield, a major insurer in the state, plans to start paying doctors for these non-visit activities. And Anthem is not the only one to do so, she explains, but rather the latest example of a new trend. Just this week, Aetna announced a similar program in which certain doctors who actively manage their patients’ care will receive monthly payments for that work.

It’s all part of a move toward the medical home model, which we’ve covered before in this blog. According to the American College of Physicians, this model places the personal doctor at the center of a web of continuous and coordinated care for patients, throughout their lifetime. This personal doctor organizes referrals to specialists and other providers when needed. Those who support this model, Ms. Becker writes, say that it reduces costly emergency room visits and improves the quality of care – a win-win situation.

The details of Anthem’s program have yet to be determined. So far, it includes rewards for primary care practices that show improved health outcomes and lower costs. Eventually, like in Aetna’s program, doctors who play an active role in coordinating their patients’ care will receive a monthly payment. Anthem’s goal is that one day, all primary care doctors will fit that description.