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Dave Barry: Freewheelin' fun at the DNC

This vibrant Western city has pulled out all the stops to make Democratic convention visitors feel welcome right from the moment they arrive at the huge and modern airport, conveniently located in nearby Kansas. From there it's less than a day's drive to downtown Denver, which has been spruced up for the convention with the installation of thousands of brand-new, state-of-the-art spittoons.

These stereotypes are totally false, except the one about the mayor, who actually is named John Hickenlooper. I happen to semi-know Mayor Hickenlooper, because I belong to an all-author rock band called the Rock Bottom Remainders, and when we performed in Denver two years ago, Mayor Hickenlooper joined us on stage to sing the classic Troggs song Wild Thing. Really. He took the difficult vocal solo part that goes, ''You MOVED me,'' and he totally nailed it. You would have sworn you were hearing an actual Trogg. The mayor got a nice round of applause from those audience members still able to clap without falling down. I mention this story because I really like saying ''Hickenlooper.'' Hickenlooper Hickenlooper Hickenlooper.

But my point is that, despite the mayor's name (''Hickenlooper''), Denver is a modern and sophisticated city with huge quantities of culture in the form of museums, latte machines, flush toilets, etc. And the city has done a fine job with the convention preparations, which include many ``green'' touches, such as the ''Freewheelin'' free-bicycle program. As I understand it, the way this works is, there are nearly 1,000 bicycles in special racks set up around Denver, and if you feel like offsetting some carbon, you just go to one of these racks, and you realize that all the bicycles have been stolen.

At least that's how it would work in Miami. Apparently in Denver, people actually return the bicycles. Ha ha! What a bunch of cow-town Hickenloopers.

No, seriously, I applaud this program, as well as the many other ''green'' efforts at this convention, such as the bold plan to take the 19,000-seat Pepsi Center ''off the grid'' and power it entirely with delegate flatulence, even though this has forced Barack Obama to move his Thursday acceptance speech outdoors.

Speaking of the convention: It got off to a rousing start Monday night with speeches by three or four dozen important Democratic party dignitaries, who sounded the convention's official Monday theme: ''A Whole Lot of Speeches.'' But the big news was the decision to seat the entire Michigan and Florida delegations, which means they will be able to participate fully in the roll-call vote, which means you just know the Florida delegation will mess up the buttons somehow and accidentally nominate Walter Mondale.

Meanwhile outside of Denver, Joe Biden has wasted no time acting vice presidential, attacking John McCain for being out of touch with ordinary Americans because he couldn't remember how many houses he has. I think this might backfire. For one thing, Joe is not really one to accuse anybody of being out of touch, seeing how he has been a U.S. senator for 200 years. But also there's the question of fairness. I mean, do YOU have a perfect memory? Can you look yourself in the eyeball and honestly say that you have never forgotten how many houses John McCain has? I know I have. Sometimes I forget my own pants.

Speaking of which: I am shocked to report that there are lavish parties being held here, financed by huge evil corporations giving away free food and liquor to advance their evil corporate agendas. As a journalist concerned about corruption, I cannot BELIEVE I have not been invited to any of these parties. Give me a call, giant corporations! I'm right here in my hotel room! With about 45 bicycles.

Health care no longer primary ailment; Economy, price of gas, war in Iraq have surpassed insurance as top election issue for candidates

WASHINGTON

What happened to health care?

In the daily rat-a-tat-tat between Sens. John McCain and Barack Obama, the silence is deafening.

It was once the "it" topic of public policy that helped propel the Clintons into office, sparked open warfare among special interests, and then toppled a Democratic Congress.

For a while, health care was that which was not spoken about following the 1994 legislative debacle. For Sen. Hillary Clinton, it was something that taught her great lessons. And in the drawn- out Democratic primary fight between her and Obama, the cost and availability of health care were daily fodder in the debate over which candidate would do a better job as president.

And now, there is ... not much.

The continual tussle between the two presumptive presidential nominees -- Obama and McCain -- has largely centered recently on national security and the high price of gasoline. Public opinion polls have shown that among the top issues of concern to Americans, health care is languishing far behind the economy, the war and the price of gas. One CBS poll from July put voter interest in health care at just 3 percent. In August, it was at 8 percent.

\ Trumped by gas

"For a lot of people who have health insurance, they are paying more for health care, but it may not show up as concretely as paying $70 to fill their gas tank," said Anna Greenberg, a Democratic pollster.

This week, the Obama campaign criticized McCain's visit to an oil rig off the coast of Louisiana and held a conference call with Tom Vilsack, the former Democratic governor of Iowa, to complain about McCain's opposition to an energy bill pending on Capitol Hill. It also announced a "Next Generation Veterans for Obama" group that will participate at the Democratic convention, and accused McCain of questioning Obama's patriotism.

The McCain campaign, on the other hand, promoted new numbers from the Gallup Poll showing that veterans solidly back McCain, a Navy veteran, over Obama. It also criticized Obama's support for equal pay for women as a cash cow for trial lawyers. And it accused Obama of lacking credibility on the international stage and engaging in theatrics to make up for his deficiencies.

There were no conference calls to talk about health care. There were no television ads about health care. On the campaign trail, Obama responded to a question Monday from a voter on the subject.

To be sure, both campaigns offer detailed -- but very different -- health-care plans. While both say they want to provide affordable, high-quality health care for all, they go about it quite differently.

McCain, for example, would eliminate favorable tax treatment for employer-sponsored health insurance and provide individuals with tax credits of $2,500 per person or $5,000 per family to buy insurance. He would promote competition among the insurers by allowing people to choose insurance companies outside their state.

Obama, on the other hand, would require all children to have health insurance and would require employers to offer health benefits to workers or contribute to the cost of a new public plan. He would expand Medicaid, which provides health coverage to the poor and the disabled, and he would expand SCHIP, the children's health insurance program.

On Capitol Hill, Democratic and Republican staffers have already begun meeting in preparation for work on health-care legislation next year, even if they don't know who will be president.

Rep. Rahm Emanuel (D-Ill.), chairman of the House Democratic Caucus, said he's seeing an energetic debate about the cost of health care in House races around the country, though it is not the top topic for the presidential candidates right now.

"College costs, health-care costs and energy costs are up, and income is down," Emanuel said. "Any one of those subjects touches a raw nerve for the middle class in this country. I'm seeing it in race after race."

Emanuel and other Democrats say they expect Obama to highlight health care at the Democratic convention in Denver next week.

\ 'Still a top concern'

Obama's spokesman, Bill Burton, said the problem is the press, not the campaign.

"The issue of health care may be getting less attention than it deserves from the media, but it's still a top concern for voters and among the top issues that Sen. Obama talks about on the campaign trail," said Burton.

Tucker Bounds, a spokesman for McCain, acknowledged that the issue has not been prominent so far.

"However," he said, "There is a stark contrast in the way both candidates would address the issue. Because the views on providing affordability, accessibility and portability of health care are so divergent, it could hardly escape the conversation each candidate will have with voters."

Still, as the cost of gasoline skyrocketed this summer and as voters brace themselves for the high price of home heating oil and natural gas, public opinion has shifted on what matters most.

\ Signs for health costs

Many political analysts attribute the rejiggered priorities to the in-your-face nature of gas station signs advertising the price of gasoline.

"If people had to pass that many signs that announced how much health care costs, you can bet it would be at the top of the agenda," said Matt Bennett, a founder of Third Way, a Democratic think tank, and former adviser to Vice President Al Gore. "It is strikingly different from 2000, when Gore spent 60 percent of the time at most events talking about health care."

Gary Ferguson, a Republican pollster who specializes in health care, said that even though the issue seems to be lagging, it's still part of people's economic concerns.

Drew Altman, president of the Kaiser Family Foundation, called gas prices "the canary in the coal mine" for economic worries.

"Beneath all that, when you probe, when you ask people what's bothering you about the economy right now, in economic downturns -- problems paying for health care and health insurance really loom large," Altman said. "After people's fixations paying for gas prices, problems paying for health care are right at the top with job issues."

- - -

Comparing the candidates' health-care plans

John McCain

Would provide a tax credit of $2,500 per individual and $5,000 per family to purchase health insurance.

Would eliminate favorable tax treatment for employer-sponsored health coverage and allow individuals to cross state lines to purchase insurance in order to promote competition.

Would work with states to create a "GAP" program -- Guaranteed Access Plan -- for people denied coverage because of pre-existing conditions. Financial aid would be provided to those below a certain income level.

\ Barack Obama

Would require all children to have health insurance and would require employers to offer health benefits or contribute to the cost of a new public program.

Would expand Medicaid, which provides health coverage to the poor and the disabled, and would expand the SCHIP program, which provides coverage to lower-income children.

Would create a National Health Insurance Exchange so that people without access to health coverage and small businesses could enroll in the new public plan or in approved private plans.

SOURCE: The Kaiser Family Foundation at www.health08.org

----------

jzuckman@tribune.com

(Copyright 2008, Chicago Tribune. All Rights Reserved.)

Is Low-Cost Health Insurance Worth It? Premiums look low, but you give up a lot of expensive medical coverage -- that is, you transfer the risk from the insurer to yourself

Infomercial king Billy Mays, known for screaming about the wonders of cleaning solutions Kaboom!, OxiClean, and other household products, is now starring in a commercial for what he calls "the most important product I've ever endorsed:" health insurance. The bearded salesman started pitching iCan Benefit Group's "health insurance that you can actually afford" in May 2008, pointing to the need for its health plans given that 47 million Americans are uninsured. In the commercial, Mays says iCan's plans include guaranteed acceptance, starting as low as $160 per month for individuals and $260 for families, and can allow you to lower your monthly premium, increase coverage, or both. Concludes Mays: "You can't afford not to make this call."

Mays is understandably "passionate about health care." We all need health insurance, yet many Americans can't afford it, while the cost of the plans and of medical care keeps rising. Mays is pitching iCan's Mini Medical, a type of limited health insurance for those who can't afford major medical insurance or have been turned down because of preexisting health conditions.

Low Premiums Mean High Risk

These limited plans are not for everyone, and they could end up costing more if you need expensive care. "The problem is they're advertising these unbelievably low premium health insurance plans," says Mark Kenison, a financial adviser who specializes in insurance at Turning Point Benefits Group in Charlotte, N.C. "All you're doing its transferring risk to yourself so your monthly premiums are lower."

Consumers might focus on the low monthly price and not examine the cost and coverage of each health service, Kenison says. Beware of policies that don't set a maximum amount that you'd be responsible for paying for a health service, he advises. For example, iCan's mini-medical plan will probably not provide enough coverage if you get badly injured or need surgery. Looking at an example of the company's lowest-cost offering, iCan's mini-medical plan costs an individual $160 per month in North Carolina -- plus an additional, $100 one-time enrollment fee -- and covers a maximum of just $1,000 for surgery per year, with anesthesia limited to $250 per surgery. If you're hospitalized, the plan would cover only $200 for the first day and $100 each additional day, with a maximum of $1,100 for up to 10 days. On average, hospital care is estimated to cost $1,931 a person per year, according to the latest figures [2004] from the U.S. government's Centers

for Medicare & Medicaid Services.

The low maximum benefits -- and the prospect of huge additional out-of-pocket expenditures -- bothers some financial pros. "It just feels wrong," says Kenison, adding that most people would be better off getting a major medical plan that limits their risk to a certain dollar amount.

If you end up with a large medical bill, members of iCan's health plans have a health advocate to negotiate pricing and hospital charges, says Harold Shatz, managing member of iCan Benefit Group in Boca Raton, Fla. A $40,000 to $50,000 medical bill can be reduced to $10,000 to $12,000 through network pricing and use of a health advocate to examine the bills and find errors, he says. iCan's plans, Shatz says, are based on studies that found that 95% of people with major medical health plans did not have expenses that exceeded their deductible, and are geared for people who can't afford or get coverage. Shatz calls iCan's medical plans a "concierge service that gives you access to the medical community before you need it and when you need it, and holds your hand through it and helps you negotiate the pricing to what it should be."

"It's a very common-sense program for people who don't have another choice," Shatz says. "It beats the heck out of having nothing."

Pushy Marketing

Advisers recommend ignoring outfits that use such strong marketing-driven tactics as iCan and 123 Health Plan, both of which offer plans through enrollment in a nonprofit organization called Health Care Credit Union Assn. [HCCUA] The HCCUA's other membership benefits include entertainment, dining, movie and travel discounts, and roadside assistance.

Consumers should understand exactly what services a health plan covers and estimate what their out-of-pocket expenses will be. Steven Weydert, a financial adviser at Bowyer, Weydert Wealth Planning Partners in Park Ridge, Ill., says his No.1 rule is to insure only things you absolutely can't afford to lose and to take as high a deductible as you can afford. A good place to compare health plans, he says, is eHealthInsurance.

If you lose your job during these tough economic times, you can sign up for your employer's COBRA health-care plan for the next 18 months. But some similar plans cost less. "COBRA might be more expensive than a policy that suits your needs," Kenison says. "Don't assume COBRA is the best way to go." Start shopping when you lose your job, as it usually takes two to four weeks to get a policy in place, he says.

Get Term Life

Amid the economic squeeze, it's vital to address other insurance needs, too. Consumers should make sure they have enough life insurance, which replaces income when you or a family member dies. Weydert recommends buying a term life policy covering 10 times your gross salary. If you want to be more conservative -- and depending on your age -- Kenison advises getting a term life policy that covers 20 times what you earn to keep your lifestyle going. So if you earn $10,000 per month, or $120,000 per year, you should have $2.4 million in term life. "This would be enough to generate $120,000 per year, using a 5% cash flow, and hopefully, you would never touch the principal," he says. That amount can be reduced, he points out, if a person can expect some other sources of income, from Social Security, say, or a pension.

Kenison also likes term life policies that are portable -- that is, you can take the policy with you if you leave or lose your job. Most companies offer a $50,000 policy at no cost, and you should be able to buy an affordable policy with additional coverage on your own. Weydert compares life insurance policies and rates for his clients at Insure.com.

Individual disability insurance [BusinessWeek.com, 8/4/08] is also a good idea, advisers say. Large corporations usually offer an employee disability plan that covers 65% to 70% of your salary if you get hurt and can't work. But your net benefit after taxes, Weydert figures, will be closer to 45% of your gross income. "Your standard of living will go way down if you take a claim, so you need another policy to bring you back closer to whole," he says. Look for an individual disability policy that covers 65% to 70% of your gross income. Also, make sure the insurance provider has a liberal definition of disability -- which will help you qualify as disabled and get benefits, Weydert says. And look for an insurer with high ratings, such as John Hancock, he says.

The loud pitch from Billy Mays might entice some consumers to buy insurance out of fear, without understanding the policy. After you shop around, find an agent who will take the time to explain the policy to you and don't buy until you understand it. Remember, says Marc Vorchheimer, an adviser at Integrated Financial Consulting in Spring Valley, N.Y.: "Your goal is to protect against catastrophe."

(Copyright 2008 McGraw-Hill, Inc.)

Canceled coverage to be restored; Insurers agree to take back policyholders dropped after they got sick. Lawyers protest state notification plan.

About 3,400 Californians whose health insurance was canceled by Kaiser, Health Net and PacifiCare after they got sick will soon receive notification that they may be eligible for new coverage and for compensation for medical bills they paid while they were uninsured.

In a deal with state regulators, the insurers agreed to offer former members new coverage regardless of preexisting medical conditions and to reimburse them for medical expenses. In exchange, the state Department of Managed Health Care will close investigations into the companies' rescission practices. Regulators began mailing out notices to individuals Tuesday.

The state's largest insurers have all been widely accused of looking for ways to drop individual policyholders who incur high costs. The insurers contend that members who are dropped have misrepresented their medical histories on their applications.

The practice has been condemned by lawmakers, judges and regulators.

The agreements between the state and the insurers were unprecedented in their ambition to restore coverage. But they also have come under fire from consumer advocates.

The mailed notices triggered another flare-up.

Lawyers for policyholders expressed concern Friday at a hearing in a suit against Health Net over a plan for the insurer to notify former members about the state agreement.

State law stipulates that such notices go through lawyers for members of the presumed class, said Mike Bidart, one of the policyholder lawyers.

What's more, he said, policyholders would eventually receive court-approved notices about developments in the case, including any settlement.

"Our concern was that it creates tremendous confusion for people to get one notice and then another," he said.

Los Angeles County Superior Court Judge Victoria Chaney set a hearing for Sept. 2 to consider the issue. Then late Monday, Bidart said he learned that the state intended to send the notices out itself.

"I'm sure they are doing this because the courts don't currently have jurisdiction over the DMHC," Bidart said. "They are basically end-running what was about to be heard by the court."

The department's executive director, Cindy Ehnes, defended her actions. She suggested that lawyers who opposed her plan were seeking fees that would result from the settlement of their lawsuits.

"Our process would not result in the millions of dollars in awards of attorneys' fees that I think these folks are contemplating," she said.

Ehnes said former policyholders could resolve their cancellations through the department's process, which would send each case to a third-party arbitrator, or wait for the outcome of the class-action litigation. "What we have tried to do is to offer enrollees options," she said.

The department reached similar settlements with Anthem Blue Cross of California and competitor Blue Shield.

--

lisa.girion@latimes.com

(Copyright 2008 The Los Angeles Times)

Health costs expected to rise 10%

Health-care costs are expected to rise more than 10 percent into next year, according to a survey of insurers by Aon Consulting Worldwide.

But that increase is the smallest Aon has seen in six years. Experts say it shows that efforts to tame costs, such as employee-wellness or disease-management programs, may be paying off.

"There's a variety of tactics that employers have been employing over the last 3 to 6 years that has had an impact on the market," said study director Bill Sharon, an Aon Consulting senior vice president.

Aon Consulting surveyed about 70 health insurers around the country, including companies such as Aetna Inc. and Cigna Corp. It found that actuaries expect costs to rise an average of 10.6 percent during 12-month rating periods starting this year between April and September.

That represents a slight drop from last year's forecast of 10.9 percent and a bigger fall from 2002, when health-care costs were expected to rise by more than 16 percent.

But the percentage likely won't be what the average employee faces for a premium hike next year. It doesn't reflect insurance plan designs or changes an employer might make to benefits plans.

"Pretty much every employer has to do something or is doing something in an effort to bring that number down," Sharon said.

He said actual cost increases have wound up being three to four percentage points lower than preliminary estimates in the past couple of years. Still, he said Aon Consulting's survey gives employers a benchmark to use as they consider premium renewals.

Many employers have started researching their benefit options for 2009. Consultants say it's too early for predictions on next year's health-plan costs.

But Ken Ambos of Equity Risk Partners Inc. said midsize employers could see a cost increase of roughly 9 to 12 percent that they pare down to 6 to 9 percent. Equity Risk Partners is a risk-management and employee-benefits consulting firm.

Costs are still rising to keep up with growing patient demand for services, the needs of an aging population and prescription drug and technology costs, according to Aon Consulting, a subsidiary of Aon Corp.

Overuse and misuse of services and an "out-of-control medical liability system" also contribute to increases, said Robert Zirkelbach of America's Health Insurance Plans, a trade association.

Zirkelbach said health insurers have offered disease-management programs and encouraged the use of cheaper generic drugs.

(Copyright 2008, Orlando Sentinel Communications. All Rights Reserved.)

New PlanPointer Online Tool Guides Consumers Looking For Individual Health Insurance with HumanaOne ; Picking a plan greatly simplified with new Internet technology; easy-to-understand language makes process quick and easy

LOUISVILLE, Ky. - (BUSINESS WIRE) - Humana Inc. (NYSE: HUM) today announced the introduction of a new online tool for consumers who apply for individual health insurance through HumanaOne, the company’s line of individual health plans.

The new PlanPointer tool – now available on Humana-One.com in most states where Humana offers individual health plans – guides consumers in selecting, personalizing and applying for a health plan that fits their needs.

“With PlanPointer, HumanaOne is transforming what can be a time-consuming process – applying online for individual health insurance – into a simpler, quicker, easier process that gives applicants confidence they have selected the health plan that is right for them,” said Steven DeRaleau, chief operating officer of HumanaOne. “Using plain language, PlanPointer guides applicants through a series of simple questions that allow them to make and refine choices, based on their individual needs.”

Sometimes in buying individual health insurance, it’s not easy for consumers to find the right balance of coverage and cost, especially while trying to make sense of insurance jargon and complex data. With PlanPointer, HumanaOne is clarifying any confusion for its online insurance applicants.

Applicants answer four basic questions regarding monthly premiums, benefit levels, prescription-drug coverage, and their interest in a health-savings account. As applicants answer each question, the list of appropriate plans narrows – with only the most relevant plans appearing at the bottom of the display.

Ron Rogowski of Forrester Research wrote in a recent report that HumanaOne’s PlanPointer tool “brings transparency to insurance purchasing …[it] guides users with embedded help that explains potentially confusing terms like “co-pay,” “co-insurance,” and prescription drug deductible.” (“Rich Internet Applications that Build Brands,” Forrester Research, March 2008).

Humana partnered with Molecular, an award-winning agency known for its ability to help companies design Web strategies and experiences that grow and strengthen their brands with customers online – especially through the use of “Rich Internet Applications” such as HumanaOne’s PlanPointer tool.

HumanaOne health plans are designed specifically for individuals and families not insured by an employer, such as self-employed entrepreneurs, small business employees, part-time workers, students and early retirees. Humana markets HumanaOne plans through insurance agents and brokers, as well as directly to consumers.

Humana guarantees monthly premium rates on its HumanaOne plans for one full year after purchase, as long as the member remains in the same area and keeps the same benefits. Thanks to Humana’s nationwide network of doctors and hospitals, HumanaOne policyholders who move to a different state can simply take their plan with them, and in most cases, those who work or travel away from home can receive in-network benefits by seeing any of the more than 400,000 Humana-contracted doctors, hospitals and other health care providers across the country.

HumanaOne members have 24-hour access to online tools and resources, enabling them to check claims status, medical expenses, compare hospital, doctor and prescription costs and more. HumanaOne accepts individual health insurance applications by phone or via its website at http://www.humana-one.com.

About Humana

Humana Inc., headquartered in Louisville, Kentucky, is one of the nation’s largest publicly traded health and supplemental benefits companies, with approximately 11.5 million medical members. Humana is a full-service benefits solutions company, offering a wide array of health and supplementary benefit plans for employer groups, government programs and individuals.

Over its 47-year history, Humana has consistently seized opportunities to meet changing customer needs. Today, the company is a leader in consumer engagement, providing guidance that leads to lower costs and a better health plan experience throughout its diversified customer portfolio.

More information regarding Humana is available to investors via the Investor Relations page of the company’s web site at http://www.humana.com, including copies of:

* Annual reports to stockholders

* Securities and Exchange Commission filings

* Most recent investor conference presentations

* Quarterly earnings news releases

* Replays of most recent earnings release conference calls

* Calendar of events (includes upcoming earnings conference call dates and times, as well as planned interaction with research analysts and institutional investors)

* Corporate Governance Information

((c) 2008 Business Wire. All Rights Reserved.)

INSURANCE Barely moving Health savings accounts haven't caught on with workers

Four years ago, the hot new idea for reining in health costs was the health savings account, a savings vehicle tied to a high-deductible insurance policy and designed to make patients more responsible for - and more aware of - the expenses involved.

The thinking was that such accounts would slow spiraling medical costs for both employers and consumers.

Today, with only 5 percent of the 114 million Americans covered at work opting for such health plans, their future is in question. In Texas, regarded as the birthplace of the HSA, only 387,000 people have signed up out of the 12 million with employer-provided insurance.

Proponents point to small companies - including some in Texas - that have used the lower-cost plans to offer coverage for the first time.

Meanwhile, critics argue that the plans benefit only the healthy and wealthy, with sick patients who can't afford deductibles of more than $2,000 doing without care.

Under the 2003 federal law that established them, HSAs must be coupled with high-deductible health plans carrying at least a $1,050 deductible for an individual or $2,100 for a family.

In return for paying so much out of pocket before coverage kicks in, the policyholder can save pre-tax dollars in an account that can grow tax-deferred - much like a 401(k) retirement plan - and be used for future health costs.

A covered individual and his employer together can make annual, tax-free deposits of up to $2,900 (or $5,800 for a family). Unused funds can be rolled over from one year to the next and go with employees when they change jobs or retire.

Despite the tax benefits, patients have not been enamored of the trade-off. Few have signed on at companies now offering HSA plans as a new option, according to the Commonwealth Fund, a private New York City foundation focusing on the nation's health care system.

"People aren't used to paying" high deductibles, said John R. Thomas, president and chief executive of Irving-based MedSynergies Inc., a company that helps physicians manage their revenue.

To be successful, an HSA must have employer support, said John Goodman, president of the National Center for Policy Analysis in Dallas. "If employers don't put money in the HSA, all you have is a high-deductible plan" - something unlikely to appeal to many employees, he said.

Mr. Goodman said high-deductible plans get at the heart of the health cost problem - overuse of medical services by people who, if they paid with their own money, might decide against that trip to the doctor.

"If a mother wakes up in the middle of the night with a sick child, we want her to think about the cost of the emergency room visit," said Mr. Goodman, dubbed by many the "Father of Medical Savings Accounts." In 1984, the NCPA suggested what it referred to as medical IRAs to address looming Medicare costs from baby boomers.

Mr. Goodman is now a health policy adviser for Republican presidential candidate John McCain.

On the other side, Stacy Pogue, a policy analyst at the Center for Public Policy Priorities, an Austin-based advocacy group, argued that HSAs favor healthy people, who don't worry about a deductible, and the rich, who have the money for a big deductible and like the tax incentives.

In fact, a May report from the Government Accountability Office found that taxpayers with health savings accounts averaged an adjusted gross income of $139,000 in 2005 vs. $57,000 for other filers.

Ms. Pogue said she worries that low-income participants will gamble with their health rather than pay a huge deductible.

An online survey of 4,217 adults ages 21 to 64 found a striking difference in use by those in fair or poor health or who have at least one chronic condition. Thirty-five percent of them reported delaying or avoiding care vs. 18 percent in traditional comprehensive plans. The Commonwealth Fund conducted the study in March.

Survey respondents said they avoided doctor-recommended visits to specialists, lab appointments and imaging tests.

But for many small North Texas employers, HSAs have been a godsend.

Kevin Whitney, chief operating officer for Dallas-based Flexible Benefit Group Inc., sells HSA policies to companies with as few as two employees and as many as 2,000. He said he has a higher success rate among the smaller firms.

In 2004, Mr. Whitney offered the 13 employees of Flexible Benefit a choice between a standard plan and an HSA. The employees chose the HSA, Mr. Whitney said.

Only a few of his mostly healthy, mostly young employees have more than $2,100 in medical claims, he said. And under the HSA, "our premium per employee is $125 less than with the traditional PPO," he said.

Still, Mr. Whitney said that HSAs should be cheaper and that insurers are not passing on the savings from the fewer claims they get.

Many of his business clients have only a 40 percent utilization rate under their high-deductible plans, he said. "For every $100 in premiums, they're only spending $40 in claims. That means the insurers are making a boat load."

He predicts HSAs will "blow away" preferred provider organizations "once the market prices HSAs appropriately."

Pricing isn't the only issue. Questions remain about whether HSAs will fulfill their promise as a savings vehicle to pay for future care.

Last year, 83 percent of HSA accounts had an average balance of less than $2,500, says America's Health Insurance Plans, a Washington, D.C., association representing insurers. The average balance in an HSA in 2007 was $1,380, it said, while the average amount spent from such a fund was $1,080. That left about $300 for savings.

Mr. Goodman predicted that HSAs will travel the course of investment retirement accounts - sluggish and confusing at first, but popular and effective later on.

"Actually, they're growing faster than the IRA grew in its history," he said.

Within 10 years, Mr. Goodman predicted, most Americans will be saving up for their deductible under the new plans.

(Copyright 2008 The Dallas Morning News. All Rights Reserved.)

medical examiner

Waiting Doom

How hospitals are killing E.R. patients.

Last month, Esmin Green, a 49-year-old mother of six, tumbled off her chair and onto the floor of the Kings County psychiatric E.R. waiting room in New York City. Members of the hospital staff saw her lying there but did nothing for about an hour. When Green was finally brought into the E.R., she was dead. An autopsy revealed that she died from a pulmonary embolism, which occurs when a blood clot forms in the leg, breaks off, and travels to one or both lungs. This can also kill long-haul airplane passengers who sit in one spot for hours: The blood sits stagnant in their legs for so long that it clots. You could say that Green, too, had been on a plane ride of sorts. She'd waited for a psychiatric-unit bed to open up for more than 24 hours, roughly the same time as a trip from New York to Tanzania.

The surveillance video of Green collapsing and lying untended, as hospital staff at Kings County fail to respond to her collapse, is inexcusable by any stretch. And so Nancy Grace, for one, focused on the negligence. But what's largely missing from this story is the likely cause of Green's pulmonary embolism. The answer lies in a far more systematic and widespread danger in hospital care: E.R. waits. Why was Green sitting and waiting while blood pooled in her legs? Despite increasing evidence that crowded E.R.s can be hazardous to your health, hospitals have incentives to keep their E.R. patients waiting. As a result, there has been an explosion in E.R. wait times over the past few years, even for those who are the sickest.

A major cause for E.R. crowding is the hospital practice of boarding inpatients in emergency departments. This happens when patients who come to the E.R. need to be admitted overnight. If there are no inpatient beds in the hospital (or no extra inpatient nurses on duty that day) then the patient stays in the E.R. long past the completion of the initial emergency work. This is what happened to Green, and it has become widespread and common. The problem is that boarding shifts E.R. resources away from the new patients in the waiting room. While E.R. patients wait for inpatient beds, new patients wait longer to see a doctor. As more new patients come, the waits grow. And an E.R. filled with boarding patients and a full waiting room is an unhappy E.R.: The atmosphere is at once static and chaotic. If you or a loved one has waited for hours in an E.R., you know what we mean. The environment can be unsafe and even deadly. A recent study found that critically ill patients who board for more than six hours in the E.R. are 4 percent more likely to die.

What hospital would promote such a practice? Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients. Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money.

In effect, then, E.R. boarding allows hospitals to insulate themselves from the burgeoning needs of the poor. E.R.s are safety nets: By law, we who work in them see any and all patients, regardless of their ability to pay. But as more E.R. beds are devoted to boarders, the E.R. has less space for new patients, which keeps a lid on the number of un- and underinsured. So unless you are having a heart attack and can jump the line, your emergency—though it may still be serious—may wait for so long that you give up and go home. Bad for you, good for the hospital's bottom line. E.R. boarding also tamps down nursing costs, again not to your benefit. Hospitals generally maintain strict patient-to-nurse ratios for inpatients. But many hospitals don't apply the same rules to the E.R. because they can't control the number of patients who come in that way. Sometimes the nursing ratio in the E.R. can be as high as 8-to-1. That's unacceptable in inpatient units, but just stack 'em in the E.R. hallways and suddenly it's OK.

What about the staff upstairs, who take care of the admitted patients once they leave the E.R.? Their incentives are misaligned, too. Put yourself in an inpatient nurse's shoes. You are overworked, and your current patients need attention. You get a call from the E.R., saying that a patient like Green is ready to come upstairs. The bed is clean and ready. But you have 20 more things to do before your shift ends in two hours, and you won't get paid an extra cent if you accept Green to the empty bed. Can't she wait just a bit more in the E.R.? When the next nurse comes on fresh, you tell yourself, she can admit the new patient. You won't get in trouble for stalling because no one really measures how long patients stay in the E.R.. So you tell the E.R. nurse that the bed isn't ready yet. This practice of "bed-hiding" is more common than you think.

What can be done about all this? We think the answer is that hospitals should have to disclose and take responsibility for how long E.R. patients—that is, you—wait for beds. But, not surprisingly, hospitals have lobbied hard to not be held accountable for E.R. crowding and boarding. If they won't measure and eliminate E.R. boarding on their own, then the federal Centers for Medicare & Medicaid Services, which pays many hospital patients' bills, or the Joint Commission, which accredits hospitals, should take this on.

And let's also hold congressional hearings on E.R. boarding. In England, the National Health System now has a rule that 98 percent of patients have to spend less than four hours in the E.R.. Apparently, the son of a member of parliament spent too long in an E.R., we've heard. Esmin Green wasn't well-connected. But her death should serve as a similar prompt to fix the problem of endless waiting.

Meanwhile, if you have to go the E.R., you can vote with your feet. When you are really sick, of course, go to the closest E.R. or call an ambulance. But if you can wait long enough to choose, go to the E.R. where they don't make patients wait or board for long periods. Yes, we know—since hospitals don't publicize E.R. waits or boarding, you'll have to go by word of mouth. If, despite your efforts, you or your grandmother is forced to lie in the E.R. all night, complain directly to the hospital administrators who actually have the power to fix the problem. But don't count on any major changes. As long as hospitals profit more from boarding and aren't forced to admit to doing it, your trip to the E.R. will be as long as a flight to Africa—but without the in-flight movie and far more risky.

Article URL: http://www.slate.com/id/2195851/

Copyright 2008 Washingtonpost.Newsweek Interactive Co. LLC

Retail Health Clinics: Convenience with Caveats

Retail-based health clinics are expanding across the country. You can find them at big drugstores or supermarkets. The idea is health care while you shop. Visits to these clinics are increasingly covered by health insurance.

Douglas Kamerow is a family physician and former assistant surgeon general. Here’s his take on whether retail health clinics are good places to go for your medical needs.

Douglas Kamerow is a family physician and former assistant surgeon general. Here’s his take on whether retail health clinics are good places to go for your medical needs.

DOUGLAS KAMEROW: The organizing principles behind retail health clinics are taken right from the fast food industry - convenient locations, quick service, long opening hours, limited menu, low prices, and consistent quality. Anything that can be done by nurse practitioners using well-accepted guidelines is in. Anything that involves too much judgment, ongoing chronic care or serious consequences is referred out.

Most patients really like them. A recent national poll found that between 80 and 90 percent of users were satisfied with the quality of care, convenience, and costs of these clinics. No surprise, most doctors really don’t like them. Medical societies around the country have expressed concerns about the quality of care and the lack of continuity of care provided by these clinics. But maybe that’s just sour grapes.

If you go to a retail health clinic, it will probably be like the one I recently visited. It was in the back of a suburban drugstore. There was a small waiting area and a sign saying that the nurse practitioner was in one of two examination rooms with a patient. I signed in and I sat down.

While I waited, a large flat-screen video display flashed promotional material alternating with the menu: ear infection, $59; flu shot, $39; camp physical, $59; and so on. The clinic took cash, credit cards and many health insurance plans, although not mine. So, should you go to one of these clinics? They are designed for people who have a simple, well-defined problem or need a shot or another offered service. Perfect for a child’s recurrent ear infection on a Sunday - quick exam, diagnosis, treatment and, of course, your prescription can be filled before you leave the store. Also, they’ve been very popular with uninsured people because of their low charges. Or if you’re on vacation and develop conjunctivitis or a sinus infection, nothing could be more convenient.

But legitimate clinical questions exist. Who assures quality of care? Where’s the medical backup and follow-up? What do they do when an emergency walks in? And how do retail health clinics differentiate a simple, minor problem from a serious problem that’s not obvious.

The clinics say that they hire experienced, certified nurse practitioners who know what they’re doing and when to get help. They follow recognized guidelines for diagnosis and treatment, and they’ll refer you out if your problem is too complicated. All the clinics have telephone backup from a doctor, although sometimes that doctor’s in another state. As for emergencies, they say they really don’t see many.

Bottom line? I think these clinics are providing a very useful service, from which conventional doctors’ practices could learn a thing or two about speed and convenience of care. Would I go to one? No, if it was for a complicated problem or related to lots of other ongoing problems I had. Yes, if I was out of town or I couldn’t get to see my doctor for what I knew was a simple, quick problem. But in either case, I’d make sure to subsequently let my primary care doctor know what the problem was and how I was treated.

BLOCK: Family physician Douglas Kamerow is a former assistant surgeon general. He lives in Maryland.

(.)

My Unhealthy Lifestyle is Your Problem! ; New Survey Uncovers Disconnect Between Responsibility for Personal Health And Who Should Pay For It

CHICAGO - (BUSINESS WIRE) - According to a new survey from The Vitality Group, a member of Discovery Holdings Limited, the vast majority of Americans (82 percent) believe that they alone are responsible for their health. They also agree that lifestyle choices, such as smoking and exercise, have a direct impact on their healthcare costs. Yet when asked who should pay these healthcare costs, nearly half of Americans (44 percent) believe they should not bear any part of the responsibility of paying for their healthcare.

((c) 2008 Business Wire. All Rights Reserved.)

E-DIAGNOSIS ON THE RISE; MORE PATIENTS ARE TAKING ADVANTAGE OF E-MAIL CONSULTS

Mike Holland came home from a business trip a few weeks ago in so much pain he tried something new: He made a doctor's appointment online. The next morning, he arrived and saw the doctor in minutes.

A week later, on the road, his new medicine made him sick. The Hollywood computer consultant logged onto the same physician consulting Web site and filled out a form detailing the problem. Hours later, he had e-mail advice from his internist, Dr. Rene Reyes.

Another electronic medical checkup completed. The small and slow-growing trend of doctor e-consults got a little bigger.

"I figured I would never even hear back from them," said Holland, 53. "Getting specific advice about the medication I was taking and the treatment I was getting was tremendous. Not having to wait a week for an appointment and not having to sit for two hours in the waiting room, that was really something."

After more than four years in the mainstream in Florida and a few states, online doctor consultations are catching on, although not like many had hoped. Only a fraction of doctors offer the service, and a small number of their patients take advantage.

\ Practice on the rise

Proponents of e-consults said the number has jumped since Aetna, Cigna and other insurers began paying for them nationwide in January. They predict the practice will one day become a prime option for patients dealing with simple health issues.

"It's really convenient for the patients and great for the doctors, too," said Dr. Maureen Whelihan, a West Palm Beach obstetrician who has consulted online for 15 months.

Blue Cross Blue Shield of Florida began offering online physician contacts in 2004 as a way to improve patient satisfaction, ease office burdens on doctors and save a little money, said Lynn Monson, the insurer's director of health information technology.

A few thousand of the insurer's 28,000 doctors belong to the various online systems, and the number is growing. From all those Florida doctors, Blue Cross pays for a dozen e-consults per month on average, although many more may be using the system for free contacts, Monson said.

"I would love to see it take off like hotcakes, but it hasn't," Monson said. "It's something that's going to come of age."

\ Popular with patients

Surveys show patients like the idea of contacting doctors by e-mail. But in California, only 4 percent of people reported doing so last year.

"The reality is that most patients unfortunately are not tuning in yet," said Dr. Nigel Spier, a Hollywood OB/GYN who answers patient e-mails daily and late at night. "Younger patients are catching on. But certainly the reflex is that if people have a question, they pick up the phone, they don't go to their computer."

To contact a doctor online, patients go to a password-protected Web site to find forms requesting lab results, prescription refills, appointments and office matters. Typically these are free and fielded by the office staff.

To initiate an e-consult about medical issues, patients answer a series of questions about their illness and medical history. The system often asks different questions depending on the patient's answers, as a doctor would. The doctor gets notified of the inquiry and posts an answer online for the patient to look up.

"When they fill out the form, all the questions I would have asked [in person] are already answered," Whelihan said. "I can actually make a pretty good diagnosis."

E-consults cost $25 to $40, payable by credit card. If insurance covers it, the patient may only face a small co-pay.

"Once [patients] use it once or twice and realize how nice it is, they use it more and more," said Reyes, who started e-consults in April.

\ Not everyone's sold

Some doctors and medical organizations are skeptical of e-consults, saying an online exchange cannot replace a face-to-face visit and increases the risk of a doctor misdiagnosing a serious problem.

"There's so much potential for miscommunication when you can't see someone's face or detect the tone of their words, or watch their body language," said Dr. David Hutchinson, president of the Minnesota Academy of Family Physicians.

Proponents of cyber-medicine dismiss such fears, saying doctors can use their judgment to restrict e-consults to simple health issues.

Reyes' hand-held wireless unit jangled with an online question from a man whose ulcer resumed bleeding one night. He said he quickly called and ordered him to the emergency room.

RelayHealth, a leading online consultation system, says about one-third of its e-consults end with the doctor asking to see the patient in person.

Doctors who like the approach tend to be younger and tech-savvy. They find that dealing online with routine illnesses and matters is faster and more efficient than taking phone calls, and produces better records.

The online systems also ease foot traffic at a time when office visits have surged by 20 percent in five years, federal figures show.

\ Coverage concerns

The fact that big insurers have started covering e-consults bodes well for growth, supporters say. Cigna and Aetna tested e-consults since 2006 in Florida and other states before going national. Insurance officials said the service fits the trend of having patients take more responsibility for their health and costs.

The number of Cigna doctors using the system jumped by one-third this year, spokesman Joe Mondy said, but still has reached only 12,000 of 500,000. At Aetna, not 5 percent of 490,000 doctors are signed up, spokesman Walt Cherniak said. Doctors may hold off unless many patients show interest, while patients may not even know their doctor has access.

RelayHealth, a California e-consult firm, has signed up 17,000 doctors since 1999, said Ken Tarkoff, vice president and general manager. Thousands more use Medem Inc., Medfusion and others.

One in 10 of Spier's 5,000 patients have signed up for his service. One in five of Whelihan's 5,000 patients have; she fields one e-consult daily.

"A lot of physicians say, 'You're so out there.' We're really not," Reyes said. "This is 2008, folks. This is a natural evolution."

Bob LaMendola can be reached at blamendola@sun-sentinel.com or                             954-356-4526               or                             561-243-6600              , ext. 4526.\ \ INFORMATIONAL BOX:

How best to use online consultations, or e-visits, with your physician:

Use e-consults with doctors with whom you already have a relationship and for minor health issues. That includes colds, follow-up questions after an office visit, routine infections, aches and monitoring an ongoing illnesses.

Do not consult a doctor online about a new illness or about potentially serious issues such as bleeding, sharp pain, a change in pain, chest discomfort, traumatic injury, or multiple, complex symptoms.

Explain your medical issue on the Web site's forms as thoroughly as possible, in plain language, to avoid misunderstanding. Do not leave out or exaggerate any symptoms. Avoid humor that could create confusion.

Explain your medical history fully, including all medications and supplements you take.

Make sure the doctor's system is secured to protect your medical privacy.

Sources: American Academy of Family Physicians, RelayHealth, Medem, Medfusion

Learn more

For tips on how to using e-consultations with your doctor, go to page 2D.

Staff illustration/Pattie Barry

(Copyright 2008, South Florida Sun-Sentinel. All Rights Reserved.)

Rx: Small price for a big payoff; A study concludes that if we eat right, exercise and quit smoking, healthcare savings could be $16.5 billion over five years, $1 billion of that in Florida. HEALTH

Spending only $10 in prevention per person may save billions of dollars in cures, according to a national study released Thursday.

Echoing the centuries-old wisdom of Ben Franklin, researchers at the Trust for America's Health, a Washington-based nonprofit group, found that simple community measures to get people to eat right, get more exercise and stop smoking can have huge benefits.

Nationally, the study calculates the savings could be $2.8 billion in the first two years and $16.5 billion over five years. For Florida, patients, and government-backed and private health insurers could save $1 billion over five years.

The findings provide hard numbers for what experts have been saying for years:

Simple measures to promote wellness and control health problems early can prevent costly visits to emergency rooms.

Two-thirds of Americans are overweight, one in five doesn't exercise at all and one in five adults smoke, the survey reported. Those conditions can lead to massive health problems, including high blood pressure, diabetes and cancer.

The study used a computer model developed by researchers at the Urban Institute and a review of evidence-based studies from the New York Academy of Medicine to come up with their findings.

They looked at dozens of studies, including communities that added after-school programs for children in parks or increased the number of bike paths and walkways to promote exercise.

In Des Moines, a program to give parents and their children information about a healthy lifestyle and weight management resulted in an average weight loss of five pounds for elementary kids and 10 pounds for those in high school after 12 weeks.

In California, a tax increase of 25 cents on a pack of cigarettes was used for health education to discourage smoking and to pay for more parks, recreation and healthcare for those who couldn't afford it. After 10 years, a study found that per capita cigarette consumption in the state had fallen by more than 50 percent.

THE MODEL

To arrive at their figures, researchers estimated how much such things as weight loss and exercise can prevent certain conditions and then looked at expense models.

''The researchers found that if the country reduced type 2 diabetes and high blood pressure rates by 5 percent, it could save more than $5 billion in healthcare costs,'' the authors noted.

Other research has also found a link between preventive programs and better health.

In January, the Centers for Disease Control and Prevention looked at the Silver Sneakers program, which offers free gym memberships to seniors enrolled in Medicare programs operated by Humana and CarePlus.

The CDC study found that after two years of membership, Silver Sneakers members had ''significantly fewer inpatient admissions and lower healthcare costs'' than those who weren't members.

A FAN

One big fan of the program is Hyacinth Chung, 69, a West Dade resident who uses a Bally gym. ``I've been going about two years now to Silver Sneakers, and it has really helped me a lot. It used to be I couldn't get up from a sofa and walk because my knees were so stiff, and I couldn't climb a stairs without running out of breath. Now I can. And my doctor says my health is excellent.''

Last month, a study by the Commonwealth Fund showed that children in Miami-Dade, where many are uninsured, have a 46 percent higher rate for hospitalization for asthma than children in Massachusetts, where far more children have insurance.

Experts believe all asthma hospitalizations should be viewed as preventable with proper preventive care.

Bernd Wollschlaeger, a primary-care doctor in North Miami Beach who is president of the Dade County Medical Association, said: ``Small investments have a large savings, but a disproportionate amount of money is spent on tertiary diseases rather than preventive care.''

Medicare and private insurers pay doctors comparatively little for dealing with high blood pressure or diabetes, but pay a lot for treating complications, such as the need for open heart surgery.

''Primary care is getting meager reimbursements'' from insurers, Wollschlaeger said, which means that medical school students are turning to higher-paying specialties, leaving primary-care doctors ''with a tremendous workload'' and less time to talk to patients about wellness and preventive measures.

Using another old saying, Wollschlaeger summed it up this way: ``We have a penny-wise and pound-foolish healthcare system.''

((c) Copyright 2008, The Miami Herald. All Rights Reserved.)

Insurers Pay Doctors To Push Generic Drugs

Two New York health insurance companies are rewarding doctors with cash incentives for prescribing generic drugs.

The companies, Excellus Blue Cross Blue Shield of Rochester, N.Y., and Independent Health, based in Buffalo, are offering higher compensation to doctors who increase their rates of prescribing generics instead of more expensive brand-name medications. The companies say the programs were designed to control the escalating cost of pharmaceuticals and to pass on savings to the patients.

Doctors say that generics sometimes can be safely substituted for brand-name drugs. But some of them also are skeptical of the payments from insurers, saying they could raise ethical questions and even jeopardize the safety of some patients.

"By offering incentives to prescribe generics, there's at least the appearance for an ethical conflict, steering toward the cheaper medication," an Albany cardiologist, Dr. Mikhail Torosoff, said. "That's upsetting."

Insurers defend the practice as a way to rein in costs.

"What we're focusing on here is how do we make health insurance more affordable, and one way of doing that is to promote more cost-effective health care treatments," the senior vice president of the New York Health Plan Association, Leslie Moran, said.

She dismissed the notion that physicians are being coerced. "Everyone likes to talk about the availability and accessibility of health care," she said, "but you can't expand access if its not affordable. A key component of affordability are costs like prescription costs."

Similar programs elsewhere in the country have come under fire. In Michigan, lawmakers and physician groups opposed an incentive program launched by a subsidiary of Blue Cross Blue Shield of Michigan, Blue Care Network, which ran a three-month program that paid doctors $100 for each patient who switched to a generic cholesterol-lowering medication from a brand-name drug.

In response to the backlash, the American Medical Association posted a position statement on its Web site that reads: "A physician accepting payment from an insurer in exchange for moving a patient from a brand name to a generic drug could potentially face both criminal and civil liability exposure under the federal antikickback statute."

Generic drugs that are approved by the Food and Drug Administration must be the "bioequivalent" to their brand-name counterparts, meaning their active ingredients must be the same, drug experts said.

But some doctors said they are wary about switching the drug regimens of patients who are doing well. Prescribing a different drug within the same class could harm a patient, some said.

"The more serious the drug, the more concerned I am about forced substitution," an associate professor at NYU School of Medicine, Dr. Marc Siegel, said.

In New York, the incentive programs offer doctors increased reimbursement if they change their prescribing habits. Under Independent Health's program, doctors who increase the rate at which they prescribe generics receive a cash reward based on their patient base. A physician who increases their rate to 70% from 40%, for example, would receive fifty cents each month for each Independent Health member whom they treat.

Under the Excellus plan, doctors who increase their ratio of generic drug prescriptions to brand-name ones by 5% receive higher reimbursement for patient office visits. The company declined to provide further details on how much doctors are paid, citing proprietary reasons, but officials said the overall goal of the program is to encourage patients and physicians to consider generics.

Officials from Independent Health said their program seeks to educate patients, but they are also rewarding doctors for doing the "extra work" associated with discussing generics with their patients. "Like it or not, physicians are in a business," the company's vice president of pharmacy services, John Rodgers, said.

Other health insurance companies denied plans to launch similar programs. But doctors said a number of companies issue "report cards" that include a tally of the prescriptions that physicians write.

At least one company, Cigna, said it issues quarterly reports to physicians as part of a "Save with Generics" program, which seeks to promote the use of generics by informing patients and doctors how much money they could have saved by avoiding costly brand-name drugs.

"The only purpose is to inform physicians of opportunities to help their patients save money on their prescription medications," the director of public relations for Cigna, Lindsay Shearer, wrote in an e-mail message.

Physicians said the letters and faxes they routinely receive from insurers, which inform them when they could have saved their patients money, amount to unwanted pressure to choose generics. Other tactics used by insurance companies to reduce costs include requiring patients to obtain prior authorization for more expensive drugs, drawing up "preferred" lists of medications, and placing medicines in tiers based on cost and requiring patients to pay more for certain drugs.

"This clearly puts the burden on the doctors to 'fall in line' with the prescribing wishes of the companies," a Manhattan cardiologist, Dr. Adam Deutsch, said.

Dr. Deutsch said most of the time there is no medical reason why a generic cannot be substituted for a brand-name drug. "In all honesty, there's like seven cholesterol drugs on the market. Does it matter? No, it doesn't," he said. "The key is interference. Why is this multi-billion dollar company writing me a letter about my relationship with my patient? To me, it's an ethical issue, not a clinical one."

In recent years, doctors have been scrutinized for accepting drug samples and free lunches from pharmaceutical companies. Both practices are common, and doctors interviewed for this article said they have accepted such gifts. But they distinguished accepting drug samples and lunches from cash incentives by describing the cash incentives as bribes.

Dr. Torosoff, the Albany cardiologist, said he has been paid to speak at events sponsored by drug companies. He declined to say how much he was compensated, but he said the practice is different from accepting a cash incentive from an insurance company because as a lecturer he is performing a service and because he only lectures on FDA-approved drugs and their intended uses.

Dr. Torosoff said pharmaceutical companies have also funded research at the hospital where he works, Albany Medical Center, but he defended such grants by saying he did not personally benefit from them. Regarding the free lunches he has accepted from drug companies in the past, he described the meals as an "advertising" opportunity for pharmaceutical companies. "It's laughable to think I will prescribe something that is harmful to my patients because I got a five-dollar lunch," he said.

Officials from the state's medical society said their position is clear regarding financial incentives given to doctors who prescribe generics: A doctor's primary focus should be on their patient's welfare. "I don't criticize the insurance companies for wanting to contain costs, that's a laudable goal," the executive vice president of the Medical Society of the State of New York, Rick Abrams, said. But he said when conversion is done solely for purposes of cost and not quality, "then we have a severe problem with a program like that."

At least one New York lawmaker, a state senator of the Bronx, Jeff Klein, is proposing legislation that would require all medically necessary prescriptions to be covered by insurance companies. In May, Mr. Klein's office published a report that identified widespread restrictions placed on drug coverage by 19 health maintenance organizations in New York. Of the drugs surveyed, Lipitor, which is used to lower cholesterol, and Singulair, a medication for asthmatics, were the most restricted. Eight companies restricted Lipitor's use, and 11 companies limited Singulair's use.

Mr. Klein said restrictions do not benefit consumers, particularly those who take "single-source" medications, or drugs without a generic equivalent. "They're making it difficult for people to get the drugs they need," Mr. Klein said.

(Copyright 2008 The New York Sun, One SL, LLC. All rights reserved.)

Behind Rising Health-Care Costs; New technologies for medical treatment can push prices sharply higher, even when the benefits are modest. Low-tech solutions can be more effective

Why do medical costs keep going up? Walk into the University of Maryland Medical Center for a heart bypass operation and you'll see one reason. Maryland is one of the few hospitals in the country to use a robot for heart surgery. Developed first by the military and then for commercial use by Intuitive Surgical (ISRG), the da Vinci robot is manipulated by a surgeon seated several feet away from the patient. The machine takes minimally invasive surgery to a new level, allowing the tiniest of incisions and enabling doctors to operate in extremely tight places. The robot is already a popular option for prostate surgery, and proponents praise its ability to trim patient recovery time by a third.

It does not, however, do the same for the hospital bill. A da Vinci robot costs $1.5 million, and every time it is used in the operating room, some $2,000 worth of parts must be replaced [for safety reasons]. It takes a surgeon 12 to 18 months to learn how to use the machine, and a da Vinci operation usually takes longer than a hands-on procedure. Consequently, a University of Maryland study estimates that the robot adds about $8,000 to the price of bypass surgery.

Another study from Dartmouth Hitchcock Medical Center points out that it's tough for most hospitals to earn back the price of the machine, if it wasn't donated. On top of all that, "There is really no convincing evidence that the da Vinci is any better than standard surgery," says Paul Levy, president of Boston's Beth Israel Deaconess Medical Center [which does not have one]. "Doctors and hospitals that have one are promoting it, and patients are demanding it," Levy says. Patients are usually unaware of the increased cost of the robot, since their insurance pays the bills. Also there's no competitive pressure to lower costs, as Intuitive Surgery is the only company that makes a surgical robot.

Medical Price Inflation to Blame?

Price insensitivity on behalf of customers, lack of competition, technological complexity -- they all adds up to immense inflationary pressures on health-care costs. Technological advances go hand in hand with productivity gains in most industries, but in medicine, better technology almost always means higher expenses. PricewaterhouseCoopers estimates that medical costs will rise 9.9% this year and 9.6% in 2009, even though the overall inflation rate for the most recent quarter was 4.2%.

Some of this higher spending can be attributed to the greater medical demands of an aging, overweight population. But the California Healthcare Foundation says medical price inflation, not increased use, drives 51% of the growth in health-care spending. The federal Agency for Healthcare Research & Quality [AHRQ] found that from 2000 to 2004, the mean cost of a hospital stay per patient rose 15%.

If You Build It, Patients Will Come

Rising costs could be seen as a sign of progress: The cheapest medical outcome, after all, is death. Major advances in the treatment of heart disease, cancer, pulmonary disorders, and a broad range of once-fatal diseases have prolonged life, but the longer the life, the higher the medical costs. "We're not realizing cost reductions as a result of increased longevity," says Michael Thompson, principal with PriceWaterhouse Coopers. Survive a heart attack, for example, and you raise your chances of living long enough to die of cancer or Alzheimer's disease, two of the most expensive diseases. Not to mention the cost of the drugs and follow-up care you'll need to avoid another heart attack.

Medical costs are also affected by the Field of Dreams syndrome. If you build it, patients will come. Develop or improve a treatment for an unmet medical need, and demand will soar. Take anesthesia: Studies by the Kaiser Family Foundation show that better anesthetic drugs have resulted in faster patient recoveries and lower cost per patient. But the improvements also made it possible to perform surgery on patients once considered too frail, adding to the health-care burden. These patients are inevitably costlier to treat than their more robust counterparts.

Better medical technology is rarely simpler technology. Implantable cardiac defibrillators, used to regulate the heartbeat of patients who have suffered serious damage to the heart, took decades to perfect. These tiny and complex devices, made by Medtronic (MDT) and St. Jude Medical (STJ), can reduce the risk of death from a heart attack by 30%, a significant benefit. Almost half of heart attack survivors now receive one, up from 9.5% in 1995. But the cost of implanting one can run anywhere from $68,000 to $102,000.

Different Rules from National Health Care

At least the value of the implantable defibrillator is well established. The Congressional Budget Office has estimated that less than half of all medical treatments are supported by rigorous evidence proving they work. And cost-benefit analysis, required by many countries before a new treatment can be approved, is almost taboo in the U.S. The Food & Drug Administration is forbidden by law from considering the cost of a new device or drug when deciding whether to approve it. Thus treatment with the new generation of highly individualized, targeted cancer drugs, such as Genentech's (DNA) Avastin or ImClone's (IMCL) Erbitux, can cost $100,000 or more, though they add only a few months of life for most patients. They do offer, however, a slim chance of a longer benefit to some patients. So cancer victims demand them, and doctors recommend them in the hope they might get lucky.

That doesn't happen in countries with universal health care. In Europe, for example, the cost-benefit of a new treatment is part of its evaluation. Britain's powerful National Institute for Health & Clinical Excellence [NICE] just recommended against using Avastin for early treatment for lung and breast cancer because it didn't believe data support the high price. In the U.S., an insurer will rarely deny payment for a treatment based on price. Also in other nations, drug prices are determined by the national health service, a bargaining power legally denied Medicare.

Expensive Learning Curve

New treatments can also go quite wrong, expensively wrong, especially early in their product life as doctors adjust to using them. Bernard Friedman, senior economist with the AHRQ, says complications and malfunctions are among the main causes of the rising cost of individual treatments. Bariatric surgery, which reduces the stomach size of severely obese patients, can dramatically improve health outcomes, but as many as 14% of patients may end up back in the hospital from complications. Spine surgery, one of the more common surgical procedures, also has a notably high complication rate, and the sophisticated tools used to perform the operation are becoming more and more costly. As a result, the cost of a spinal fusion rose 93.6% from 2000 to 2004, to an average of $50,000.

The one area of medicine where innovation has been rare and costs are still low is prevention. "Right now, we spend a lot on the last 30 days of a patient's life," says Dr. Daniel Jones, chief of minimally invasive medicine at Beth Israel. "We could think of improving the quality of a patient's life rather than the length, by spending more money on preventive care." Getting patients to lose weight, quit smoking, and exercise more would go a long way toward reducing medical costs, he said. In medicine, the low-tech solution can be the most productive.

(Copyright 2008 McGraw-Hill, Inc

What We've Learned From the Massachusetts Health Plan

It may come as a surprise to some on the left, but it is the Bush administration that made the state of Massachusetts' health-care revolution a reality.

Health and Human Services Secretary Michael Leavitt, together with Massachusetts leaders from both parties, enabled our state to launch a health-care plan that is on track to get virtually every citizen insured. Moreover, Bay Staters are now able to own their own insurance with the same low rates that are paid by employers. And there is no more worrying that if you lose your job, you lose your health insurance.

The Bush administration will decide in the coming days whether to continue to facilitate this experiment by accepting the state's financial contribution as qualifying for federal matching funds as in the past. If the federal government refuses or reduces federal participation, the state could be forced to curtail the program.

The plan has critics as well as proponents; I hope both can agree that what we are learning is invaluable. Here's how I see it:

There is a misconception in this country that individuals who do not have health insurance also do not receive health care. But in fact, people without health insurance regularly show up at emergency rooms -- and by federal law, they are treated, usually at no cost to them. The cost is picked up by everyone else, and by government.

Our plan said no to "free-riders." Massachusetts residents are now required to have health insurance. For those earning less than 300% of the federal poverty level, there is a subsidized insurance program called Commonwealth Care. Individuals pay a share of their monthly premium, based upon their income level. This is private insurance, chosen by the individual. It is not Medicaid or Medicare.

For those earning over 300% of the federal poverty level, we created a "Connector" to enable individuals to purchase private insurance at lower rates, and with pretax dollars.

Already, the number of uninsured has been cut by 340,000 -- more than half. Some have signed up for Commonwealth Care, some have purchased insurance through the Connector, and some have purchased insurance through their employer. In fact, ours is the only state in the nation where the number of people purchasing through their employer has actually risen. Within two years, nearly every Massachusetts citizen will have health insurance.

The subsidized Commonwealth Care program accounts for about two-thirds of the new enrollments to date. This is as expected: We initiated this subsidized program well ahead of the unsubsidized program, and the incentives to purchase the unsubsidized insurance have only recently begun kicking in.

Hundreds of thousands of people are receiving better health care, including preventive care and treatment for chronic ailments. These people will be far less likely to suffer acute -- and expensive -- conditions in the future.

When fully implemented, almost everyone who is not on a federal entitlement program will be paying for all or a portion of their health-insurance cost. We have tackled the free-rider problem.

The cost and value of health insurance for individuals who purchase their own insurance has improved markedly. Before our plan, a healthy 37 year old (the median age of our insured population) paid $355 a month for insurance. Now, the Connector reports that that same individual can purchase insurance at just over half the cost and with double the benefits.

The cost of the insurance policies that are offered through the Connector is actually less than what was originally forecast. Market forces are beginning to go to work in health care.

Still, there are corrections that are needed. The Massachusetts plan is more costly than it needs to be. Critics overstate the cost problem by ignoring the hundreds of millions it saves by replacing prior programs for the uninsured. Even so, mid-course corrections can significantly lower cost and improve the program. Here are a few:

-- Require everyone to pay something. My plan did just that, but the state legislature decided that the poor (those earning at or below the federal poverty level) should pay nothing. If people get something for free, they don't value it and they overuse it. Further, the individual's share of the Commonwealth Care premium must be regularly adjusted for both fairness and budget.

-- Remove coverage mandates. Mandates such as unlimited in vitro fertilization drive up the cost to the state and to the individual. In an abundance of caution, the legislature voted to keep all mandates in place even as it put a moratorium on any new mandates. Now that the plan is working, the governor and the legislature should revisit this issue.

-- Phase out direct payments. We must follow through on the agreement to end direct state payments to the hospitals that care primarily for low-income patients. The legislation calls for the last payment of $160 million to be paid in 2009. Stick to this phaseout, as agreed.

-- Strict enforcement. Tighten the requirements for the free care that is still being provided by hospitals, and follow up with strict enforcement. Hospitals have grown accustomed to these dollars and will resist giving them up. Large opaque payments to hospitals must be replaced by the subsidy that is given to individuals who purchase their own insurance.

-- Cost containment. Vigorously promote the cost containment features that were contemplated in the original legislation, including cost and quality transparency among providers and co-insurance options for purchasers.

Health-care reform is working in Massachusetts. The people of the state, having the closest view of the plan, are the most positive: A recent poll shows favorable opinions outnumber unfavorable by three to one.

The left argues that to get everyone insured, the federal government must take over health care. Leaders from both parties in Massachusetts and the Bush administration have proven them wrong -- this will be one of their signature achievements. It would be a mistake to walk away from it now.

---

Mr. Romney is the former governor of Massachusetts.

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((Copyright (c) 2008, Dow Jones & Company, Inc.))

((Copyright (c) 2008, Dow Jones & Company, Inc.))

CAMPAIGN TARGETS HEALTH INSURANCE HEALTH CARE FOR AMERICA NOW ADS URGE UNIVERSAL, AFFORDABLE COVERAGE

In three South Florida cities and nationally, a coalition of unions and social interest groups kicked off a $40 million campaign Tuesday to push for universal and affordable health insurance.

The main thrust of the Health Care for America Now campaign is ads depicting everyday Americans lamenting costly health care and coverage denials, reminiscent of the insurance industry's "Harry and Louise" ads in the 1990s that helped kill the Clinton national health plan. This time, insurers are the bad guys.

(Copyright 2008, South Florida Sun-Sentinel. All Rights Reserved.)

(Copyright 2008, South Florida Sun-Sentinel. All Rights Reserved)

AMA grades health plans on how they handle claims

July 01, 2008 [American Medical News]

Chicago -- The AMA has launched a campaign to fix a claims-payment system that doctors say requires them to spend precious time and their own money to get paid what they're owed by insurance companies.
As a starting point for its Cure the Claims campaign, the AMA released a report card at its Annual Meeting in June comparing the administrative accuracy and efficiencies of Medicare and several commercial payers. The report showed that insurers' claims payments are often late and inaccurate, explanations for denials are inconsistent, and payment rules are sometimes impossible to decipher."The AMA report card results clearly convey the daunting task confronting physicians and their staff, just to get paid for the services they have earned," said AMA Board of Trustees member William A. Dolan, MD, who introduced the initiative to members and delegates at the meeting.
Doctors sometimes spend as much as 14% of their total collections on claims administration, and the AMA wants to see the average lowered to 1%, Dr. Dolan said.
"While health insurers insist on high standards for physicians reporting medical claims, I'm afraid they hold themselves to a lower standard of accuracy for processing these claims," he said.
In some cases, health plans questioned the AMA's methodology in compiling the report card but also said they were analyzing the results to find ways to improve.
Eliminating, or at least reducing, the inefficiencies in the current billing system could save millions of dollars and time, freeing physicians to care for patients rather than worrying about getting paid by insurers. That could result in lower health insurance premiums and improve the quality of care doctors deliver, Dr. Dolan said.
"The current system is unacceptable," he said. "The health care system can no longer afford the cost of the current claims processing."
The National Health Insurer Report Card was based on data culled from 5 million claims billed electronically to Medicare and seven commercial health plans: Aetna, Humana, Cigna, WellPoint-owned Anthem Blue Cross Blue Shield, Coventry Health Care, Health Net, and UnitedHealth Group-owned UnitedHealthcare.
The AMA's analysis revealed that it is possible to reduce drastically or virtually eliminate the problems endemic in the health plans' claims-payment systems, because Medicare has done it in most cases, said Mark Rieger, CEO of National Healthcare Exchange Services, a physicians' claims service firm that provided the claims database for the report card project.
Improving claims processing
Cigna spokesman Joe Mondy said that the health plan disagreed with the way it was measured in some areas. For instance, it scored poorly for not listing the date a claim was received on one form when the date actually is disclosed on a different form. But, he said, the company shares the goal of improving the claims-processing system.
"There are some challenges, but it's the first year of the study, and hopefully we'll be able to work with the AMA in refining the methods so it's more meaningful in the future," he said.
A spokeswoman for UnitedHealthcare, Cheryl Randolph, said the health insurance giant was proud to have done well under some measures in the scorecard, including having a low rate of denials and being third best for payment timeliness.
"While we fully accept our accountability in terms of ensuring claims are paid accurately and on time, we believe that physicians and their billing services also share in that responsibility and have opportunities to facilitate their performance," she wrote in a statement. "In order for claims to be processed as efficiently and promptly as possible, both insurers and physicians need to strive for accuracy and timeliness. For example, data show there is often a significant lag time between when services are provided and physician claims are submitted."
Peter V. Lee, executive director for national health policy for the Pacific Business Group on Health, asked doctors to take responsibility for health care costs by holding down their own costs. The group is a nonprofit consortium of business leaders advocating for transparency in health care pricing and accurate, useful quality information for patients.
Lee said business leaders are beginning to understand how critical it is for doctors and other health professionals to be paid correctly and quickly, and are demanding it of health plans.
"That doesn't mean paying claims blindly," he added.
Marcy Zwelling, MD, a primary care physician from Los Alamitos, Calif., and a delegate for the California Medical Assn., said the AMA's campaign isn't the only answer to physicians' frustrations over billing, claims and reimbursement.
She said she has gone to a cash-based practice and no longer deals with insurance companies. She encouraged doctors who could afford it to make the same leap.
"It took a lot of courage for me to say no," she said. "But it's better [now]."
Former family physician and University of Chicago researcher Lawrence Casalino, MD, PhD, is working on a project similar to the AMA's report card. He said anonymous interviews with health plan executives for his research revealed that the people running claims-payment systems know they don't work well, and those systems could be improved if one company would take the first step.
"I don't think there's any disagreement that there's opportunity for improvement in the system," he said.
Dr. Casalino remembered the relentless frustration he and the other doctors in his group felt trying to be paid on time and accurately for their work.
"For 20 years I would go home with the uneasy feeling that I was leaving money on the table."

  ADDITIONAL INFORMATION: 
The AMA's solution
The Cure the Claims campaign offers a prescription for addressing the cost of getting paid for care. Campaign materials outline ways for doctors and health plans to reduce wasted time and money spent on paying doctors.
How to fix it
Physicians should submit claims quickly and accurately the first time.
Health plans should pay in a timely manner and at the contracted rate.
Plans should make available fee schedules, proprietary edits, payment policies and other payment information on their Web sites.
Plans should standardize the language and reasons for claim denials to reduce ambiguity in the pay process.
What the fixes should do
Reduce physicians' claim submission costs from the current 14% of collections to 1%.
Reduce waste and inefficiency.
Source: American Medical Association

Patients increasingly spelling primary care 'E.R.'

As it becomes harder to schedule an appointment with a primary care physician, more people are turning to the emergency room for routine treatment -- and those visits are driving up health care costs, creating long waiting times and tying up resources.

And it isn't just the uninsured or medically indigent who visit emergency rooms to treat a cold or a cough. The Annals of Emergency Medicine studied the problem and found that the percentage of emergency room visits by high-income patients increased from 21.9 percent during 1996 to 29 percent during 2004.

"It doesn't matter what their income is, or if they have insurance," said Venita Pine, director of nursing at Peak Vista. "Everyone is using the emergency department in ways that drive up costs."

Teri Mandell, director of emergency services at Penrose-St. Francis Health Center said one reason for the increase in emergency room visits is that patients don't want to wait to see their primary care physicians.

"If they're new in town, it could be two months before they can see a doctor -- the waiting time for new patients can be that long," she said. "We don't have enough doctors available. It's about access, and this is the only way they can access care."

Patients know that an emergency department visit can take hours, but they also know that any additional tests, such as X-rays or blood work, will be done before they leave. Prescription medicine also is available without a having to go to a pharmacy.

"All the components of service have to be there, regardless of whether or not there is an actual emergency," Mandell said. "The lab work, the CAT scans, the x-rays -- it all drives up the costs. Having trauma doctors available also drives up the costs."

Patients also are being referred to emergency rooms to reduce the workload at busy primary care practices.

"No one does house calls," said George Hertner, medical director at Memorial North's emergency department. "So doctors are becoming increasingly more likely to rely on the emergency room."

Creative alternatives

Peak Vista and Memorial Health Services have received a grant from the Centers for Medicare and Medicaid Services to provide patients with information about emergency room alternatives.

"We'll have outreach staff members from Peak Vista at the emergency department ... (to) introduce them to Peak Vista and to a primary care doctor within the system," Pine said.

While the pilot project only involves people who have Medicaid or are eligible for the program, the hospital hopes that it will reduce emergency room costs.

Mandell said that some large emergency rooms have created clinics to treat pediatric, diabetes or asthma patients, keeping them out of the emergency department. But Memorial doesn't have that capability.

Despite efforts like clinics and the Peak Vista and Memorial partnership, the problem is only getting worse, said Steve Berkshire, a health administration professor at Regis University.

"When I was in hospital administration, it was always a problem," he said. "People who didn't have a private physician would show up for anything, everything. And it's getting worse. People look at it as a way of getting care -- not as a place to have real, serious emergencies treated."

Hertner said that some patients also feel a sense of entitlement to health care services.

"Some people feel that health care is a right, and they have the right to access it at any time," he said. "Sometimes, people just don't know that there are other options out there."

And some patients also are simply using emergency rooms because of convenience.

"There's a high percentage who use the E.D. on the weekends because they don't want to wait until Monday morning," Mandell said. "It's a community problem -- and we have to recognize it as one."

In addition to added costs, Berkshire said that providing routine treatment at emergency rooms also increases the risk of bad debt.

"You have to put them through the triage system before you know if it's an emergency," he said. "Even people who have insurance, something like an HSA, can be surprised by how expensive care in the E.D. can be."

Credit: Amy Gillentine

Creative alternatives Peak Vista and Memorial Health Services have received a grant from the Centers for Medicare and Medicaid Services to provide patients with information about emergency room alternatives.

(© 2008 Colorado Springs Business Journal. Provided by ProQuest Information and Learning. All Rights Reserved.)

More Americans Delay Health Care --- Cost Concerns Drive Even the Insured To Forgo Treatment

An increasing array of Americans, many with health insurance, are delaying or forgoing medical care because of concern about cost, according to a report from the Center for Studying Health System Change.

About 20% of the respondents in a 2007 survey of 18,000 people said that they had put off or gone without needed medical treatment at some point in the year earlier, up from 14% in a 2003 survey.