We spoke with an underwriter at Humana who said that we had to wait at least 12 months after having the lipoma removed, and then have a doctor write a letter stating that it was gone.  We finally got around to having that done last week.  Jay got a note from a doctor here in Broomfield that says that the lipoma is gone.  We also have a copy of the receipt from the original removal procedure.  Tomorrow we’ll submit the paperwork to Humana, and hopefully the lipoma exclusion will be deleted from our policy soon.

It’s a lot of hoops to jump through, but if you have an individual health insurance policy in a state like Colorado that allows pre-existing condition exclusion riders, you might want to double check to see if your rider can be re-evaluated.  Most carriers in Colorado require that the condition be resolved (treatment and symptom free) for at least a year before you can request a review of the rider.  Some exclusions will never be removed, like the internal fixation rider on Jay’s arm.  He has a titanium rod in his arm from a snowboarding accident years ago, and as long as the rod is in his arm, the exclusion will remain.  Since the rod is permanent, so is the exclusion.

But other exclusions can be subject to review once a condition is resolved.  The same applies to someone who quits smoking.  If you pay tobacco rates on your individual health insurance policy and then quit smoking, you can request that your rates be reduced.  Most carriers in Colorado require that you be smoke-free for 12 months before the rate can be lowered, but it can make a significant difference in the premium, and is definitely worth pursuing.

Money was a major factor, on both sides.  People like Primavera (herself a cancer survivor) and the patient advocate groups were likely working with patients’ best interests in mind.  But my guess is that the pharmaceutical industry wanted this bill to pass because they would like the extra revenue that would be generated if all the health insurance carriers in Colorado had to start covering oral chemotherapy.  Estimates from Kaiser Permanente of Colorado pegged the cost of oral chemotherapy at more than nine times the cost of using intravenous chemotherapy.  That would seem like a very good motivator for pharmaceutical companies to get involved.

Of course, those numbers also reflect the reason the bill was killed.  There’s no way that this bill would have passed without premium increases going along with it.  One lawmaker estimated that it would have increased premiums by $147/month for every insured family in Colorado.

Proponents of the bill noted that oral chemotherapy is much less intrusive for a patient: the person can continue to go to work and lead a somewhat normal life, taking medicine at home rather than going to a hospital or clinic for chemotherapy treatment.  For my own family, at-home dialysis has made my father’s life much easier than it was when he had to go to a dialysis clinic three times a week.  So I do understand the desire to be able to take a pill rather than go to a cancer center for treatment.  But while dialysis can go on for years (my dad has been on dialysis for nearly eight years), chemotherapy is a relatively short-term treatment.  I’m sure that people going through chemotherapy would much rather have a more convenient method of getting their treatment, but at nine times the cost, it doesn’t seem that oral chemotherapy would make much financial sense.

Of couse, if there’s a difference in patient survival and overall outcomes, that would be a different story.  But if all we’re looking at is cost and ease of use, I have to say that I agree with the vote in the House committee today.  A measure that would significantly increase health insurance premiums for Colorado residents doesn’t seem like a good idea, especially when there’s a less expensive alternative (intravenous chemo) to the chemotherapy pills.

We’ve used lots of different criteria for picking doctors; how we go about it depends on the situation.  When Jay needed to have a lipoma removed last year, and we knew we’d have to pay for it ourselves since it was excluded as a pre-existing condition on our health insurance policy, he did a lot of shopping around before selecting a doctor.  We wanted to use a dermatologist, since we assumed he would get a better outcome with a specialist (we’ve since talked to people who’ve had lipomas removed by primary care docs and had great outcomes and a lower bill.  Live and learn).  But price was our primary concern, and that was the criteria we used to pick a doctor.  Not that it did us any good.

When Jay injured his knee last year, we knew that it would likely need surgery and that we were going to have to meet our health insurance deductible no matter what doctor we saw.  It wasn’t a dire emergency, so we had time to compare doctors.  When we found out that Dr. Steadman and the Steadman/Hawkins clinic are on our PPO network with Humana, our decision was easy.  For his knees, Jay’s primary criteria for picking a provider was quality, and driving back and forth to Vail numerous times this year was worth it to us for the quality of care that he received.

When we were expecting our son last year, we chose a midwife based on a recommendation from a friend.  We knew we wanted a homebirth, and we trusted our friend’s recommendation.  Our midwife was fantastic.  Her price was about average for this area for someone with her level of experience (she’s been a midwife since I was in middle school – this is one area where I’d rather pay a little more for someone with experience).

When our son was born, we asked our midwife if she could recommend a doctor for him.  We trusted her, and knew that she worked with a lot of parents with values similar to ours.  She recommended a family practice doctor who takes care of a lot of babies that our midwife has delivered over the years.  She’s on our PPO network and has been a good fit with our family (all we’ve had so far is well checks, so going to the doctor has been pretty easy).  She’s in Boulder, which is a bit of a drive for us, but our midwife’s recommendation mattered to us, so we’re willing to make the trip.

Recently I needed to see a podiatrist.  It was a relatively minor issue that ended up needing two office visits of about 15 minutes each.  We’ve already met the deductible on our HSA this year, and since I knew that my foot could be fixed by pretty much any podiatrist, my only criteria was to find the one closest to our house and on our health insurance network.  I ended up finding a doctor in Broomfield about 3/4 of a mile from our home.  He did a great job, although I’m sure any doctor would have done just as well.  For me, all that mattered was convenience.

So my family – with a relatively limited medical history – has run the gamut of decision making protocol that people use to pick providers.  Cost, quality, convenience, personal recommendation… we’ve done them all.  I think that it depends on the situation.  For a serious health problem, it probably pays to search for quality.  But then again, a personal recommendation might get you a doctor who makes you feel more comfortable – and that’s hard to quantify.  Healthcare is a complicated issue – one that involves reason, emotion, and logic all at once.  Obviously we want the best outcome, but we also need convenience and affordability and a doctor with whom we ‘click’.  Quality rankings are a piece of the puzzle for sure, but they’re not the only piece.  I do think they will get more popular as time goes by and especially if health insurance carriers start actively encouraging patients to choose doctors from among the highest ranking providers on the comparison sites.  But there are other factors that go into choosing a provider that can’t be quantified on a spreadsheet or a graph.

In Colorado, there are 12 counties with at least 29.7% of their population living without health insurance.  Interestingly enough, eight of those counties are clustered in the southwestern portion of the state, including San Miguel county, where Telluride is located.  Telluride is a playground for the rich and famous, with multi-million dollar homes and an $1850 season ski pass.  But for a good number of the not-so-rich-and-famous who live in San Miguel county, being uninsured is unfortunately a way of life.

The counties with the lowest percentage of uninsureds were mostly clustered along the Front Range, with Douglas County having the lowest overall number.  In Broomfield County, where we are located, our uninsured percentage is between 11.8% and 17.1% – lower than the national average of 17.2%.  But overall, the percentage of Colorado residents without health insurance is higher than the national average.

I think such micro-analysis of the uninsured population in America is long overdue, and I’m hopeful that the addition of the health insurance question to the US Census forms will help lawmakers and health insurance carriers target the hardest hit areas when new policy designs and future government health care subsidies are introduced.

In other news, the Colorado Health Insurance Insider had an article included in this week’s Cavalcade of Risk, hosted by Wenchypoo.  Not surprisingly, a large portion of the articles in the Cavalcade were focused on economic risk and the financial markets.  I’m still hopeful that next year will bring about health care reform that will make health insurance more accessible and affordable and reduce the number of dark green counties on that census map.  But with all eyes on the global financial situation at the moment, I’m wondering how much further health care reform will be pushed to the back burner as the government works to stave off a financial meltdown.  And how much money will be left over for health care reform once all of the bailouts and government buyouts are said and done.

According to the articles I’ve read, the primary source of the contamination is unmetabolized drug residue being excreted in human waste and flushed into the water system.  So the over-medicating of our country is not only triggering higher health care costs and less prescription coverage on health insurance policies; it’s also causing our water supplies to be contaminated with drug residues.

In addition to human excretion, millions of pounds of unused prescription drugs are flushed into our wastewater systems every year.  Hospitals, nursing homes, pharmacies, and prisons flush controlled drugs that are expired, contaminated, or simply not needed.  If a patient dies with a nearly-new supply of medications on his nightstand, the left overs are flushed.  Why are we not recycling these massive quantities of unused drugs?  If we follow the money, my guess is that they get flushed because it’s better for the pharmaceutical industry’s bottom line to sell a whole new supply of drugs, even if there are excess drugs that could be used instead.  Drugs packaged in bottles do present a contamination risk once the bottle has been opened.  But how difficult would it be to package all pills in blister packs, with unused portions protected from contamination and available for reuse?  Patients could be provided with child-proof containers for storing their blister-packs of pills, and left-overs could be returned to pharmacies and drug makers for re-distribution.

The overuse of antibiotics to treat ailments that are self-remitting (and to clean ourselves and our homes) has increased concerns about “superbugs.”  Imagine the superbugs in our sewers if unused antibiotics are being flushed down drains in hospitals and other institutions – along with copious quantities of bacteria that tend to hang out in hospitals.

The problem of pharmaceuticals in our water supply in Colorado and throughout the US is scary and formidable.  Drug companies should be required to implement safe systems for re-distribution of unused medications.  Health insurance carriers should put pressure on pharmaceutical companies in this regard, since drugs that are getting flushed down the toilet weren’t free – and chances are they were either paid for by a private health insurance company or by the government.  Pharmaceutical companies should stop pushing their wares on doctors, and shouldn’t be advertising to consumers either.  If we could get to a point where prescriptions were seen as a last resort, and unused portions were always passed on to other patients, perhaps we wouldn’t need to worry about what’s coming out of our faucets.

This article surprised me, because I had assumed that emergency room overcrowding was directly related to the ever-increasing number of uninsured people in the US. It makes sense that if people don’t have insurance they may put off seeing a doctor as long as possible, and end up with complications that require emergency care. But it turns out that people are using the ER for the convenience factor. ERs are ever-open, treat (or at least examine) everyone who comes through their doors, and can offer a wide range of tests, procedures, and medical services. And they’re attached to hospitals, so if an admission is necessary, it’s a pretty easy process.

Overcrowding in emergency rooms is a serious problem in the US health care system. Our assumptions that it’s related to the lack of health insurance seems to be wrong, but it’s still an issue that needs to be addressed. One solution might be to have more urgent care centers, and have them be attached – or very near – to hospitals. Urgent care facilities can handle many of the lesser injuries and illnesses, freeing up ER space and staff to treat the most gravely ill. Treatment at urgent care facilities is generally less expensive than it would be in an ER, simply because at urgent care the overhead is lower. If everyone with injuries or illnesses that were not life or limb threatening were to utilize urgent care centers instead of the ER, the overcrowding problem in emergency departments – the places designed to save lives – would be much less of an issue.

So why don’t people use urgent care centers instead of the ER? I can only speak for myself here, but I think part of the problem might be location. I can tell you where three hospitals – and thus three emergency rooms – are within 20 minutes of our home in Broomfield Colorado (and if we were to go a few miles down the road to Denver, there are several more). But I don’t know the location of any urgent care facilities near our home. So in the event of a serious illness or injury, my first reaction would probably be to head for an emergency room. If hospitals were to set up urgent care centers near their emergency rooms, it would encourage patients to self-triage and choose the less-expensive urgent care in many cases. Since insured patients are obviously using the ER in large numbers, it would benefit health insurance carriers to promote the use of urgent care centers for their insureds, and maybe even to sponsor the creation of new centers.

I’ve had a lipoma on my right shoulder blade for the past 5 years. I didn’t do anything about it right away because the doctor told me they aren’t harmful and don’t need to be removed. In the past few years I’ve kinda wanted to get it removed, but it has been excluded by our health insurance because we have an underwritten individual/family policy. Also, we’ve always had higher deductible plans that wouldn’t have covered it unless we’d met the deductible anyway, even if it wasn’t excluded.

Lately though, I’ve been reading about how people have been having their lipoma’s removed by a dermatologist in their office instead of having a much more expensive outpatient surgery done in a hospital. In Colorado, the prices can be ~$500-$600 for a dermatologist compared to ~$2,000+ for an outpatient surgery. I pulled up a list of Broomfield area dermatologists close to me using Humana’s provider finder and started calling around. I told them it was a baseball sized lipoma on my right shoulder blade.

One doctor told me it would be between $200 and $300. Another one told me it would be between $300 and $500. And another one told me it would be around $600. The rest told me I’d have to schedule a consultation before they knew what needed to be done. Anyway… I’m talking to some doctors and I’m going to have them give me an estimate on the cost and whether they’ll be able to remove it in their office.

But the point is, most people who are covered under an expensive group health insurance plan through their employer might not have needed to worry about the cost. So they don’t have any reason to shop around like I did and the doctor has no reason to keep the price down either.

This is a perfect example of the point consumer driven health care (CDHC) advocates are trying to make. Here is an exerpt of a post called “HSAs Explained“, from the “Father of Health Savings Accounts”, The John Goodman Health Blog:

Suppose we passed a law tomorrow prohibiting all insurance companies (including Medicare and Medicaid) from paying any medical bills less than $5,000. What would happen?

The medical marketplace would transform almost overnight. Within a couple of months, there would be no such thing as a primary care physician (PCP) who did not post prices – at least for routine procedure PCPs would offer telephone and email consultations. They would keep patient records electronically (just like lawyers and accountants). Overall, there would develop a teeming, bustling, entrepreneurial marketplace for primary care, diagnostic tests and most prescription drugs.

Specialty markets would develop for the chronically ill, as doctors competed for their business instead of trying to avoid them. Patient education would become an emerging field, with providers offering to teach diabetics, asthmatics, etc. how to manage their own care. Internet drug sales would double, triple and quadruple, as brand drugs faced increasing competition from generic, therapeutic and over-the-counter substitutes. At the same time, overall health care spending would plummet.

Add in the fact that consumer driven plans don’t keep people from seeking needed medical care, and consumer driven plans like HSAs present a very good alternative to the traditional system.

The bill has great intentions and could help out a lot of people. But something this costly, $13.2 million price tag for next year and a $61.5 million bill for the 2008-09 fiscal year, needs more time for discussion. This bill was just proposed too late in the session.

Sen. Shawn Mitchell, R-Broomfield, questioned why such an important and expensive bill is coming through so late in the session. By trying to cram discussion of an enormous change to the health care system into a one-hour hearing, legislators are not allowed to study what drawbacks it would have or what programs might be cut to accommodate it, he said.“This bill may be the most enlightened proposal to come to this body this year or it may be a well-intentioned, wrongheaded turn in the wrong direction,” Mitchell said. “All of that bears examination.”

Even though it has such great possibilities, it’s expensive. If something like this is rushed through without thinking, it could backfire and stunt the movement to get coverage for all uninsured children in Colorado.

Gov. Bill Ritter and legislative leaders have warned lawmakers to think twice about moving bills with big price tags, making it likely the proposal faces a rougher road when it heads next to the Senate Appropriations Committee.

The measure from Reps. Bernie Buescher and Dianne Primavera, D-Broomfield, would also set aside $1.5 million from the state’s tobacco settlement to pay for vaccinations of girls who don’t have health insurance.

“We can end cervical cancer so I don’t understand what we’re waiting for,” said Primavera, who got cervical cancer following treatments for breast cancer.

Buescher said the bill, set for a hearing Thursday, is separate from the one being considered in the Senate. He said he got the idea from talking to his daughter, a medical student, who had worked with women with cervical cancer, and said he has not been working with the vaccine maker Merck & Co.

The Senate measure would require doctors to tell parents of about the availability of the vaccine that prevents infections from two strains of the sexually transmitted human papilloma virus, or HPV, which causes cervical cancer. Under the current version, girls entering the sixth grade would have to show their school proof that they have been vaccinated or that their parents signed a form rejecting it. However, lawmakers are considering changing it so that information would be kept private.

Merck had lobbied for the Senate bill and other similar bills in other states until last month, when it suspended its national lobbying effort following criticism from parents and medical groups.

Maybe more testing needs to be done on this vaccine before it becomes mandatory.