When visiting the doctor’s office for a checkup, most of us have our height and weight measured – along with blood pressure and other indicators of general health. But it turns out that not all doctors act upon this data. According to an article by Judith Graham of Kaiser Health News, published in the Washington Post, translating height and weight into a standardized measure of body fat known as body mass index or BMI is an important first step in screening for obesity. Yet, a survey found, fewer than half of family doctors reported checking BMIs for children older than 2.

That applies to adults, too. According to a report (PDF, p. 36-37) by the National Committee for Quality Assurance, an organization that works to improve the quality of health care and health insurance plans, only 40.7% of private HMOs and 11.6% of private PPOs keep track of patients’ BMIs. The numbers are slightly higher for Medicare and Medicaid insurance plans, but remain lower than they should be. However, Ms. Graham writes, certain providers and insurers have begun routinely collecting BMI measurements.

Of course, checking BMIs is only the first step in treating and reducing obesity. Once patients are found to be at risk for obesity-related medical issues, the next step is to steer them toward information and programs on nutrition and exercise. And therein lies the challenge – medical school does not train doctors on handling weight issues, and many doctors don’t have the expertise, awareness of quality programs, or clinical time to advise patients themselves.

In addition, insurance companies haven’t generally reimbursed doctors for BMI screening and follow-up counseling. However, health reform is slowly changing that. New rules state that insurers must cover preventive medical services for patients free of charge, which include screening for obesity and recommending behavioral changes to patients at risk. Medicare also covers up to six months of weight loss counseling for patients who are obese.

Insurers have also introduced their own weight management programs, Ms. Graham explains. Examples include UnitedHealth Group’s Join for Me, a year-long program for children and teens, and WellPoint’s effort to coordinate care for overweight children between primary-care doctors and dieticians. As we’ve described previously, many insurers are also using financial incentives to persuade members to adopt a healthy and active lifestyle.

Readers, does your health provider collect data on your height and weight, and do they act upon it? What would you like insurance companies to do to help you maintain a healthy weight?

For more information, see:

• HBO: The Weight of the Nation, airing May 14-15, 2012 at 8:00pm
• Institute of Medicine: Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, released May 8, 2012

When state-based online health insurance exchanges debut in 2014, customers could have that same reaction if too many plans are available, according to an analysis published in this month’s Health Affairs and summarized in an article by Sam Baker of The Hill. Instead of allowing any plan that meets state standards to participate in the online exchange, the analysts argue, states should take an active role in narrowing down the choices to a manageable number.

Rosemarie Day and Pamela Nadash, the health policy experts who authored the analysis, based their findings on data from Massachusetts, where a state health insurance exchange was established in 2006. Customers in Massachusetts preferred to choose from a small number of plans that had been approved by the state and were described in detail online. Ideally, they would want four to six options with high, medium, and low levels of coverage, Mr. Baker explains. This allows the state to become more of an adviser to the customer, rather than simply regulating and managing the exchange.

In the United States, Medigap and Medicare Advantage follow this general approach, as do the Dutch and Swiss programs internationally, write Day and Nadash. In contrast, Utah’s exchange allows any plan to join the exchange as long as it meets certain minimum requirements.

Readers, if it were up to you, how many plan options would you like to have? At what point would you start to feel overwhelmed by the number of choices?

Related posts:

• Nov. 18, 2011: Doctors Support an Open Marketplace for Health Insurance
• June 20, 2011: Debating the Role of Health Insurance Exchanges

Now, many health insurance companies are starting to push for an alternative that can cost less and be more convenient for patients: web- and telephone-delivered health care. According to an article by Phil Galewitz of Kaiser Health News, such services have existed for years. Originally, they were created to deliver care remotely to people living far away from a provider. Recently, though, insurers such as Aetna, Cigna, and UnitedHealthcare have begun to encourage their use and cover them for a more general group of patients looking to save time and money.

For simple health issues, these services allow patients to receive health care and necessary prescriptions outside of business hours and without leaving their home or office, often at a cheaper cost than an office visit. Patients who have used telemedicine programs mostly have good opinions of them, Mr. Galewitz writes, and the industry is poised to grow rapidly, nearly tripling by 2016 according to an estimate by BBC Research. Many doctors are also on board with the concept.

However, critics worry that telemedicine patients are missing out on the benefits of an in-person visit – particularly those who don’t already know their doctors. This effect would be magnified for patients who replace regular, in-person checkups with remote appointments that take place only when a problem comes up. In today’s tough economy, some worry, it can be tempting to do just that.

To address this problem, many state medical boards forbid telemedicine appointments between doctors and new patients. Unless the appointment results from a referral, these rules require doctors and patients to have already had an in-person visit prior to the phone or online appointment. However, some medical boards are weakening those requirements.

Readers, would you feel comfortable getting treatment for a routine health issue over the phone or online? Would you be more likely to choose a health insurance plan that covers telemedicine?

According to an article by Michelle Andrews of Kaiser Health News, laws in more than half of states allow insurance companies to refuse to cover treatment for injuries relating to alcohol or drug use. That can include any injury taking place while the patient is under the influence. Large companies that self-insure their employees can decide whether to cover these ER visits, regardless of state.

The first of these laws was passed in 1947, and others quickly followed. However, explains Ms. Andrews, treatments and understanding of addiction improved over the years, and studies started to show that such policies did not improve health outcomes. As a result, more than 15 states repealed, modified, or outright reversed their laws to forbid denials of coverage based on drinking or drug use.

Instead of discouraging patients from drunk driving, those studies showed, coverage denials actually discourage emergency personnel from testing patients for alcohol or drugs in their system. Thus, the medical staff doesn’t know whether the patient has been drinking or using drugs – though they may be able to guess – and misses an important opportunity to get them into counseling or treatment.

A recent study in the Annals of Emergency Medicine examined that opportunity by measuring whether a seven-minute counseling session combined with a follow-up phone call reduced harmful drinking in ER patients. They found that six and twelve months later, patients who went through the counseling drank significantly less per week and binged significantly less often than those who didn’t. Whether there was a follow-up phone call or not didn’t have much effect.

Readers, does your plan cover emergency treatment for patients who are under the influence? Do you think it should?

Now, about a year later, walk-in clinics are not the only way insurers are shaking up their traditional businesses. Jay Hancock describes some of their approaches – and the new ethical dilemmas they bring about – in an article for the Washington Post. A few examples:

• In 2010, UnitedHealth Group, the parent company of the health insurer United Healthcare, bought Executive Health Resources (HER), a company that helps doctors and hospitals demand payment from insurers that they think they are owed. If a provider hires EHR to ask for additional reimbursement from United Healthcare, EHR would face conflicting motives from its client and its parent company.
• Three years earlier, United also acquired the Lewin Group, a health policy research organization whose analyses were used in the debate over health reform. The ownership casts doubt upon whether the Lewin Group’s policy reports can be truly independent.
• In 2011, insurance company Aetna acquired Medicity, a technology company that builds systems for providers to electronically share medical records. If the insurance arm’s access to medical records is not strictly managed, premiums and coverage decisions may be affected.
• Similarly, in March, Blue Cross plans in two states and the technology firm Lumeris bought NaviNet, a company that aggregates medical records and claims information for a group of doctors. If that information is accessible and usable by people making coverage decisions, it may affect those decisions.

Although these expansions strengthen the ties between health firms and have the potential to make care more efficient and cohesive, questions come up when insurance companies “buy traditional business adversaries,” as Mr. Hancock puts it. Acquisitions of technology companies, research organizations, physician groups and hospital consultant “[raise] questions not only about independence but about the privacy of patient information,” he explains.

Readers, if your insurance company also helped to manage your medical records, would you worry about your premium rates changing or your privacy as a patient? Similarly, if your insurer partnered with or owned a health policy firm, would you fully trust the analyses and opinions of that firm? Or, would the increase in efficiency and closely coordinated care balance out the possible conflict of interest?

Many insurers already met the MLR standard, but this was the first time it’s been legally required. If insurers end up with too much revenue at the end of the year, they can return the extra to consumers as rebates.

Now, the first cycle of those rebates has begun, and according to estimates from the Kaiser Family Foundation (KFF), they’ll make a lot of consumers happy. More than 3 million individual market policyholders – one in three of those who buy their own coverage, reports Julie Rovner of NPR – and thousands of employers will receive a total of $1.3 billion in rebates. That averages out to $127 per person, writes Ricardo Alonso-Zaldivar of the Associated Press. Some consumers have already started receiving their rebates, and all must be notified and paid by August 1 of this year.

By the numbers:

• Individual market consumers will receive about $426 million total, mostly in Texas, Oklahoma, South Carolina, and Arizona.
• Hawaii is the only state where no one will receive a rebate (Alex Wayne, Bloomberg).
• Texas consumers and businesses will receive the most in rebates of any state, totaling about $186 million (Susannah Jacob, Texas Tribune).
• Florida comes in second, with about $148.5 million in rebates (John Dorschner, Miami Herald). Other state-specific totals come in at $14.6 for Connecticut residents and businesses (Arielle Levin Becker, Connecticut Mirror) and $30 million for Georgians (Andy Miller, Georgia Health News).
• According to a separate analysis by Goldman Sachs, UnitedHealth will pay about $307 million, Blue Cross Blue Shield Plans will pay about $250 million, Aetna will pay about $177 million, WellPoint will pay about $94 million, and Coventry will pay about $50 million.

Supporters of the health overhaul see the rebates as a sign that the law is cutting health costs and returning surplus profits to consumers, as it was intended to do. According to the KFF analysts, the MLR rule – in combination with federal review of premium increases over 10% – also discourages excessively high premiums in the first place, since insurers don’t want to be criticized when they issue rebates or lower their proposed rate increases.

But skeptics of the law say that for many people, $127 won’t cover even one month’s premiums. They add that other parts of health reform, such as benefit requirements and restrictions, will end up increasing premiums and other costs for consumers.

Readers, did you receive a rebate? Were you surprised to get it? Were you surprised by the amount?

For more information, see:

• Kaiser Family Foundation, 4/26/2012: Insurer Rebates under the Medical Loss Ratio: 2012 Estimates

When thinking of different types of health professionals, physical, occupational, and speech therapists are generally classified as specialists. As a definition, it makes sense; therapists go through special training and rarely, if ever, provide primary care. But when it comes to health insurance fees for therapy appointments, the question gets murkier. Unlike a one-off consultation or small set of appointments with other kinds of specialists such as neurologists or surgeons, a bout of therapy usually involves a series of appointments scheduled frequently – something like twice a week for three months. And higher co-payments for so many sessions can add up.

That’s the reasoning behind proposals in several states to place limits on how much insurance companies can charge patients for therapy. According to an article by Julie Appleby of Kaiser Health News, South Dakota and Kentucky have already passed such limits, and similar bills are being debated in Pennsylvania, Missouri, and New York. The details vary from state to state, but most would force insurers to charge the same price for therapy co-payments as primary care co-payments.

As may be expected, insurance companies tend to oppose these limits. In Ms. Appleby’s article, Robert Airkelbach of America’s Health Insurance Plans is quoted as explaining, “Anytime you have benefit mandates, it results in more expensive coverage (premiums), and in some cases, can inhibit patient access.” Rules that set co-payments for therapy – or any other specific treatment – cut down the range of possible options for consumers. For example, a consumer who doesn’t anticipate needing therapy may prefer a plan with lower premiums but higher therapy co-payments. If co-payments are set, such plans would not be available.

Readers, what do you think of such proposals? Would you prefer to have lower premiums, risking higher co-payments in case you one day need therapy?

Expanding coverage for young adults and introducing high-risk health insurance pools were major parts of the 2010 law. However, according to a blog post by Christian Torres of Kaiser Health News, the survey results showed that the groups most likely to benefit from these provisions weren’t always aware of them. While most respondents knew that young adults under 26 would be able to stay on their parents’ insurance plans, 40% of those age 19 to 29 – the group that stands to benefit – were not aware of it. As of December 2011, federal officials estimated that 2.5 million young adults have gained coverage since the law was passed, but that number appeared to be plateauing. Low awareness within the target group may be the reason.

Similarly, 45% of people in fair or poor health and 65% of people without insurance did not know about the high-risk pools. These pools were created to help people who would not find affordable coverage in the private market. In general, Democrats, minorities, young people, and people with low incomes were less likely to be aware of both provisions than Republicans, whites, older groups, and those with higher incomes, respectively.

But a lack of awareness is not the only challenge that the survey found. According to an article by Noam Levey of the Los Angeles Times, 26% of survey respondents were uninsured during part or all of 2011. Of those, more than half (57%) had been without health insurance for two years or longer. Another 12% were uninsured for one to two years.

Sadly, many of those without coverage had tried and failed to get it. According to the overview of survey results, 31% of the uninsured were charged a higher price, had a condition excluded, or were outright denied due to a preexisting condition. 62% of people who tried to get health insurance in the past three years found it very difficult or impossible to find an affordable plan. Of those who tried, one of the report’s charts shows that 45% ultimately did not buy coverage, most (73%) of whom blamed high premiums, deductibles, and co-payments.

The Commonwealth Fund predicted that when health reform is fully implemented in 2014, these coverage gaps will decrease. This assumes that the law, which is currently being considered by the Supreme Court, is upheld.

Recently, two insurers with customers in six states proposed premium increases that HHS has designated as ‘unreasonable.’ HHS has asked the two insurance companies, Assurant Health and United Security, to either reduce the rate hikes or offer customers rebates. It’s important to note that although HHS can ask insurers to publicly explain increases, it does not have the authority to block the ones it finds unreasonable.

According to an article by David Morgan of Reuters, the proposed increases would affect about 60,000 people in individual and small group plans living in Arizona, Louisiana, Missouri, Montana, Nebraska, and Wyoming. The rate hikes were, for some plan members, as high as 24%.

In addition to being unusually high, the federal analysis found that the higher prices would break the health law’s medical loss ratio (MLR) requirement, which states that insurers must spend at least 80% of premium revenues on actual medical expenses. (Assurant’s analysts disagreed, and said that the increases were calculated with the MLR in mind.) If revenues are too high for that, insurers must give customers rebates for the excess amount.

Readers, under what circumstances would you consider a 24% premium increase reasonable – are there any? Given the goal of reducing unnecessary premium hikes, does HHS have the authority it needs to fulfill this goal, without being able to directly block rate increases?

Related post:

• 11/22/2011: HHS Deems Proposed Premium Increase in Pennsylvania ‘Unreasonable’

But as it happens, that is the conclusion of a new analysis by Buck Consultants, a division of Xerox. According to an article by Adam Belz of the Des Moines Register, health insurance costs for all types of plans are projected to go up by 9.9% in 2012. That may sound high, but it actually marks the first year since 2001 that increases have been in the single-digits. Buck has conducted this study annually since 1999, and this year’s analysis surveyed 129 insurance companies and administrators across the country.

Why the slowdown? The study authors have a few ideas. First of all, due to the current recession, many people have trimmed their health expenses to only those that are necessary and put off optional treatments and services, hoping to reduce out-of-pocket costs.

In addition, when the Affordable Care Act was passed in 2010, many insurance companies responded by increasing premiums and co-payments in the 2011 iterations of their plans, in order to pay for the law’s new requirements.  In the 2012 versions, these requirements had already been accounted for, and so, prices did not have to increase as much. In an article for The Hill, Sam Baker points out that the new results could poke holes in Republicans’ argument that health reform will increase health costs.

There was a similar trend in prescription drug costs, which will go up by 9.6% this year, compared to 10.7% in 2011. Besides the factors we’ve already mentioned, this could also be because many brand-name drugs have recently begun going generic, which lowers prices for consumers who choose the generic version.

Still, Mr. Belz writes, the growth in health care costs far exceeds the inflation rate and salary increases, which means that health care continues to eat up more and more of people’s spending.