Mind The Gap: The Insurance Gap

Michelle Singletary shares her perspective on why the plight of the American uninsured affects all of us in her column for The Courier-Journal in Louisville, KY:

The cost for those with coverage is escalating in part because the number of uninsured Americans keeps rising, said Ron Pollack, executive director of Families USA, a nonprofit organization that advocates high-quality, affordable health care for all Americans.

Using data from the Census Bureau, the federal Agency for Healthcare Research and Quality, and the National Center for Health Statistics, Families USA determined that the unpaid expenses for the uninsured added an average of $922 in 2005 to the premiums for employer-provided family health insurance. That extra cost could rise to $1,502 in 2010.

Increasingly, employers are shifting a larger portion of their health premiums to employees. You may be able to afford your policy today, but it's possible you may not in the future.

In pure and simple terms, the unpaid balances do not disappear. Instead, they get added to the balances paid by those with insurance. It is not exactly a slow process either. Singletary reports an increase of 78% in family premiums just since 2001!

She also explodes the myth that the uninsured are mostly poverty stricken. According to her reports, eight out of ten are employed, often at multiple jobs just trying to make ends meet. They are workers who fulfill important roles in our communities as caregivers and in small businesses.

The plight of the uninsured does not occur in a vacuum. Its economic impact alone touches every American in every socio-economic strata.

SOURCE: "Health-care insurance gaps affect all of us" 03/30/08
Photo courtesy of fabio, used under its Creative Commons license

The Healthy Internet

Over the course of this blog's existence, I have often touted the need for intelligent application of technology as an important part of health care reform. Usually when I do so, I am speaking of electronic medical records, e-prescriptions, or online payment systems. Today, let's take a look at the other side of the coin: public use of the Internet as a tool for mobilization and sharing of information.

Kyla King at The Houston Chronicle (via Newshouse News Service) brings us round one in the form of a story about a Michigan family who used an email campaign to apply leverage to their insurance provider:

The first e-mail arrived at 12:36 p.m. The next one followed two minutes later.

Then came the flood: More than 50 e-mails came in the first hour, and more than 300 over two days filled inboxes of executives at a health insurance company and media outlets.

That's how a father — and hundreds of friends and relatives — used the power of the Internet to keep his health insurer paying for his recently disabled daughter to stay in Mary Free Bed Rehabilitation Hospital rather than be sent home for outpatient care.

Maia Moore, 2, has been rehabilitating since an aneurysm in September nearly ended her life.

Her father, Jeremy Moore, of Grand Rapids, claims moving the toddler home goes against recommendations from Maia's doctors at Mary Free Bed.

The Information Age is certainly having an impact on the health care discussion. Social media and Web 2.0 applications are making it easier than ever for concerned citizens to mobilize, share information, and facilitate debate on the subject.

The case of Maia Moore shows how Internet tools, even basic ones like email, can make it easier to mobilize the public. Let us now take a look at a good example of information sharing, the federal Agency for Healthcare Research and Quality's (AHRQ) 2007 State Snapshots:

“This year’s State Snapshots do more than illustrate the wide variations in health care quality among states,” said AHRQ Director Carolyn M. Clancy, M.D. “They also show a handful of the important challenges that states face as they work to improve the quality of care.”
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As in previous years, the 51 State Snapshots – every state plus Washington, D.C. – summarize health care quality in three dimensions: type of care (such as preventive, acute or chronic care), setting of care (such as nursing homes or hospitals), and by clinical areas (such as care for patients with cancer or diabetes). The evaluations are expressed in simple, five-color “performance meter” illustrations that rate performance from “very weak” to “very strong.” Users may explore whether a state has improved or worsened compared to other states in several areas of health care delivery.

The tool itself is located here, and is very revealing. A quick glance at my home state of Louisiana yielded the unsurprising statistics of being weak in all metrics used.

These are only two of many examples available. Many more abound if you do a little digging. Just as technology impacts all aspects of our lives, it now also impacts all levels of discourse on any given subject. Since health care reform is one of the American public's highest priorities, a wealth of Internet resources is a mere Google search away.

SOURCE: "Dad wins e-mail fight over daughter's health care" 03/26/08
SOURCE: "2007 State Snapshots Provide State-by-state Health Care Performance" 03/26/08
photo courtesy of meyshanworld, used under this Creative Commons license

American Insurance Sends Patients to....Tijuana??

The cost of health care is a constant refrain these days. Just take a look at the wide variety of studies, news articles, and blog posts that are generated on the topic daily. Hardly surprising in an era where, as George C. Halvorson points out in his book Health Care Reform Now!, there are over 9,000 billing codes for procedures but not one for a cure.

Many solutions have been proposed, although the one embraced by a growing group of providers is novel: ship the patients to Mexico for treatment to cut costs.

Bloomberg's Thomas Black brings us the details as he reports from Monterrey, Mexico:

Yielding to pressure from employers, health insurers such as Health Net, Aetna Inc. and Blue Cross Blue Shield of South Carolina are offering cost savings to policy holders who take their ailing backs, hips and knees to foreign countries for non- emergency medical treatment. Mexico has emerged as a favored place for American medical tourists because of its proximity and U.S. insurer incentives.

Black reports about 180,000 Americans make a run for the border when they need health care each year, and spent approximately $2 billion with foreign providers last year while doing so. Why is this happening? Cost is the main factor, although Black's article reports some people stating they received better quality care in Mexico than in the United States.

A hip replacement in Mexico or Thailand costs $12,000 compared with $43,000 to $63,000 in the U.S., according to a study by Christus Health published last year. Angioplasty, in which a surgeon uses a tiny balloon to open a blocked coronary artery, costs $10,000 in Mexico, compared with $57,000 to $82,000 at an American hospital.

So that addresses the cost factor, how about that quality of care? Let's take a look at the case of Antonia Siguenza, who needed treatment for a cyst.

[In the U.S.] Her portion of the bill was $800, she said. When the incision failed to heal after several months and her U.S. doctor advised her to give it more time, she drove two and a half hours to get another opinion in Tijuana and elected to have a second procedure there.

Her cyst cleared up a few weeks after the surgery, she said.

Ana Andrade, vice president of Latino programs at Health Net says that approximately 20,000 customers have the Mexican coverage plan and also that they save roughly 40% on premiums by doing so.

While the pricing is vastly better across the border there are justifiable quality of care concerns. Follow-up care can be complicated to near impossibility, safety of the blood supply is sometimes suspect, and possible lack of legal options in the face of malpractice are valid concerns.

Black's article contains two pages of analysis as well as brief interviews with both patients and providers on this subject. He demonstrates the impact our inflated and inflating health care costs are having by demonstrating how many are opting to go outside of the American system because of finances.

SOURCE: "Mexico Gets Medical Tourists as Health Net Sends U.S. Patients " 03/26/08
photo courtesy of omar omar, used under this Creative Commons license

Health Care: Do Your Footwork Online!

Joe Light at CCN Money has consolidated a nice little list of online tools that consumers can use to make informed decisions about their health care expenditures.

It takes five minutes of Web surfing to compare prices and features and to check out customer reviews on, say, a digital camera.

But for health care? "We just haven't evolved to that level," says Jean Chenoweth, a senior vice president at Thomson Healthcare, a division of the giant information services company.

Clarity seems to be forthcoming. Many companies are launching online tools and websites geared towards this trend towards transparency. According to Light, some of the best available are run directly by the insurers themselves.

He provides a step-by-step research program for finding info about prospective providers and hospitals, including web addresses for a variety of tools and info on how to properly implement them. A few of the resources he point to include:

• ABMS.org- A site for researching whether your practitioner is board certified or not.


• Vitals.com- This site allows you to see how many times a provider has performed a certain procedure, as well as documentation of sanctions and malpractice suits.


• Leapfroggroup.org/cp- For checking to see if your hospital has proper staffing and equipment.


• HealthGrades.com- provides survival rates for patients, both while they are in the hospital and for six months following discharge.
  

There are several more tools on his list, along with explanations of how to use them, what their limitations seem to be, and what info they can provide. All in all, there is a wide ranging array of sites that should prove invaluable to someone trying to pierce the veil of medical mystery that surrounds health care in modern America.

SOURCE: "Click here for the best health care" 03/25/08
photo courtesy of barnoid, used under this Creative Commons license

Cost of Care: It'll Get You Coming and Going

Affordability is one of the big bugaboos of health care in modern America -- one that is getting steadily increasing amounts of media coverage as the serious part of the Presidential campaign ramps up. Michael A. Fletcher of The Washington Post takes a look at at the impact of these skyrocketing cost on the average working class citizens of the United States:

"The way health-care costs have soared is unbelievable," said Katherine Taylor, a vice president for Local 1199 of the Service Employees International Union. "There are people out here making decisions about whether to keep their lights on or buy a prescription."

Since 2001, premiums for family health coverage have increased 78 percent, according to a 2007 report by the Kaiser Family Foundation. Premiums averaged $12,106, of which workers paid $3,281, according to the report.

Fletcher goes on to examine the cost outlay businesses must factor in when providing health care is part of their equation, and why this is making many businesses cease offering it altogether. All in all, his opening sentence offers an encapsulated view of the issue, "Recent history has not been kind to working-class Americans, who were down on the economy long before the word recession was uttered."

So, if you manage to survive your working career without going bankrupt from health care related costs you should be in good shape, right? Wrong. If you do some digging you can find this informative little gem on Investment News (co-authored by Alicia H. Munnell, Mauricio Soto, Anthony Webb, Francesca Golub-sass and Dan Muldoon) about the National Retirement Risk Index (NRRI):

The results show that once health care is considered explicitly, the percent-age of households that will be "at risk" [of being unable to maintain their standard of living in retirement] rises from 44% to 61%. As always, the percentage "at risk" is greater for those at the low end of the income distribution. And later cohorts show more "at risk" than earlier ones due to the combined effect of a contracting retirement income system and continually rising health-care requirements.[...] Because health-care costs are rising rapidly and the income system is contracting, a much larger percentage of later cohorts will be "at risk" than earlier ones. The NRRI rises from 50% for early boomers to 68% for Generation Xers.

Seems like the cost factor has got you both coming and going. This is a clarion call for systemic reform.

SOURCE: "Rising Health Costs Cut Into Wages: Higher Fees Squeeze Employers, Workers" 03/24/08
SOURCE: "Health-care costs drive up the National Retirement Risk Index" 03/24/08
photo courtesy of Carlos Madrigal, used under this Creative Commons license

From Oregon to Pennsylvania: Quality of Care Data is Going Online

The third week of March 2008 may well be remembered for the debut of online access to quality of care info simultaneously on both the east and west coasts of the United States.

On the west coast, Kaiser Permanente* stepped up to plate as the first provider in the Oregon areaa to issue a public report on quality of care at its outpatient medical offices using nine different measures. The results are available online and debut roughly a year ahead of a regional effort of a similar nature.

The Portland Business Journal reports:

"This report is just the beginning of our plan to share our quality story with our members and the public," said Dr. Maureen Wright, assistant medical director for Quality Management and Systems. "Each year we will add more measures. For 2008, we will also be reporting scores on screening for colorectal cancer and controlling high blood pressure."

The Kaiser report uses nationally recognized quality standards called the Healthcare Effectiveness Data and Information Set (HEDIS). More than 90 percent of U.S. health plans use the HEDIS yardstick. You can access the report and look up Kaiser clinic scores at kp.org/medicalofficequality or kp.org/qualityscores.

Meanwhile on the east coast, the Pennsylvania Health Care Quality Alliance (PHCQA) launched a website on March 19 that contains similar data for all of the state's acute care hospitals. The Pittsburgh Business Times brings us the news:

The site contains information gathered from Medicare, the Pennsylvania Health Care Cost Containment Council, and the Joint Commission. Visitors to the Web page are able to search hospital quality measures in four major clinical areas: heart attack, heart failure, pneumonia and prevention of health care-associated infections.

Additional clinical areas will be added over time.

"While hospital quality data has become more available on the Internet, consumers are at a disadvantage when they must search out multiple sites, each with its own measurement standards," said Gerald Miller, chairman of the alliance. "PHCQA has developed, and is continuing to refine, a consistent and uniform approach that makes it easier for consumers to access, understand and use the data."

These bicoastal efforts are far from the whole picture. There are many significant initiatives around the country to shine a spotlight on the details of our health care transactions. As more and more people become agitated about the costs of their health care, I predict this much needed trend will sweep the nation.

The question before us is this: how will these systems interact when the areas they cover meet and overlap? At what point will we achieve the uniform standards of quality measurement necessary to enact true and lasting reform?

* Disclosure for new readers: This blog is a companion to Kaiser CEO George C. Halvorson's newest book: Health Care Reform Now!.

SOURCE: "Kaiser publishes quality data for clinics" 03/20/08
SOURCE: "Pennsylvania quality-of-care data available online" 03/19/08
photo courtesy of Unhindered by Talent, used under this Creative Commons license

Dropping the Ball in 21st Century Health Care

Today I'd like to direct your attention to an article in the Health and Wellness section of AlterNet by Niko Karvounis. Karvounis is a Program Officer with The Century Foundation in New York City where he works on issues of socioeconomic inequality and health care. He is also a regular contributor to the Foundation's health care blog.

In his article, he examines a chronic health issue, but not diabetes or obesity, instead he casts his eye upon the mistakes made when a patient is transitioned from one health care provider to another.

Even the most common hand-off -- your standard referral from primary care physician to specialist -- is not risk-free. As Dr. Bob Wachter recently noted in his blog, "in more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation." Sadly, the radio silence goes both ways: "in one-quarter of the specialty consultations," Wachter says, "the primary care physician received no information back from the consultant within a month."

These missteps are indicative of what can go wrong during the hand-off, such as, according to QSHC, "inaccurate medical documentation and unrecorded clinical data." Such misinformation can lead to extra "work or re-work, such as ordering additional or repeat tests" or getting "information from other healthcare providers or the patient" -- a sometimes arduous process that can "result in patient harm (e.g., delay in therapy, incorrect therapy, etc)."

In the era of our nations "non system" of health care, the discontinuous and fragmented nature of treatment poses many opportunities for mistakes to enter the process, often to the detriment of the patient.

Kourvanis delineates a pattern in which most of the gaps in care are communications failures and most of those are on the part of primary care physicians. To provide context, he does examine the plight of primary care doctors, doctors whose workload is mammoth and pay miniscule by comparison to others in their profession. Combined with the fee for service system currently in place, these inequities are a recipe for disaster.

He examines a variety of possible changes that could improve the system, in the end reaching this conclusion:

But for all that these ambitious changes hold promise, the hand-off will always exist -- which means reformers need to dig deeper and develop protocols at the operational level. Luckily, they're doing just that. Kaiser Permanente, for example, has created a procedure meant to formalize communication between health care teams when a patient is transitioning from one provider to another.

He goes on to look at a variety of situations and programs designed to minimize or eliminate these errors. He looks at post discharge coaching, electronic medical records, Kaiser's SBAR program and more.

Go give it a read. His article is packed not only with food for thought, but also with an amazing a array of data and hyperlinked resources.

SOURCE: "21st Century Medicine Wrought with Miscommunication and Human Error" 03/20/08
photo courtesy of Ninjapoodles, used under this Creative Commons license