Senator Bennet mentioned during his Chamber of Commerce meeting that he supports initiatives that would reward doctors based on performance, measured by patient outcomes.  He was asked what safeguards would be implemented to keep doctors from cherry-picking the healthiest patients under such a system, and replied that it was a good question that required more analysis.  I agree that patient outcomes should be a factor in determining physician reimbursement, as should medical errors and repeat hospitalizations.  But we have to take into account the patient’s health at the start of the physician/patient relationship, in addition to patient lifestyle factors.  The financial incentive has to be higher, and the outcome expectations a little lower, for doctors who take on sicker patients.  It doesn’t make sense to just set the bar at one level and expect doctors to get all of their patients to that level in order to get paid.  A 60-year-old obese smoker with heart disease isn’t going to have the same outcomes as a 25 year-old fitness instructor with a sprained ankle, no matter how careful and efficient the doctor is.

In order to truly provide quality care, a doctor is likely going to have to spend more time with sicker patients.  This should be reflected in how the doctor is compensated, along with the outcome-based incentives.  There are ways to implement an outcome-based incentive system for doctors while at the same time making sure that doctors aren’t encouraged to avoid the sickest patients.  I hope that this aspect of health care reform continues to be addressed and eventually makes its way into normal physician reimbursement arrangements.

All in all, this looks like a good deal for everyone involved.  The Take Care clinics will get widespread name recognition (already, these news reports are probably driving traffic to the clinics, in the form of people who might not have even been aware of their existance).  In addition, it’s likely that if people get good service at a Take Care clinic while unemployed, they may return again later as a paying customer.

For people who have lost their jobs and don’t have health insurance, any opportunity for free health care will help. And even if they have to visit the clinic as a paying patient in order to be eligible for free services, it’s noteworthy that the fee at the Take Care clinics normally starts at $59.  This is quite a bit less than a typical office visit charge for someone without health insurance negotiated rates.

For emergency rooms and urgent care clinics (where services are not free, but payment is often hard to collect), the free services at the Take Care clinics might help to alleviate some of the overcrowding and full waiting rooms.

The tactic of requiring that a patient have visited a Take Care clinic in the past in order to be eligible for the free health care program is a good marketing move.  It’s laudable that the clinics are offering free health care at all, and obviously they have to structure this in such a way that they don’t end up driving themselves out of business in the process.  By requiring that a patient (who might think that a job/health insurance loss is on the horizon) come in for a paid visit first, the clinics will likely boost their revenue in the early phase of this program.  Time will tell how much free health care gets handed out at the clinics over the rest of the year, but my guess is that it will be a considerable amount.

Take Care clinics operate in 32 metro areas across the country.  I went to their location finder web page and found 12 clinics in Colorado in the Denver/Boulder area, including one just around the corner from us here in Broomfield.

Last year, we found that very few individual health insurance policies in Colorado would meet CSU’s waiver requirements for grad students.  When we started looking into alternative options for Metro State students, we found only one policy met the requirements.  Although Metro State has overall a more lenient waiver requirement list than other schools, they do require more extensive mental health coverage than market driven individual health insurance policies include.  The only option that meets their requirements is the Smart Sense policy from Anthem Blue Cross Blue Shield.

We do understand the logic behind requiring college students to have health insurance.  College students tend to be young adults, in the demographic that is more likely to forgo health insurance if left to their own devices.  And a major illness or injury can derail not only their academic plans, but their whole financial future.  So we support the system that most colleges have chosen to use, with automatic enrollment in a health insurance policy unless the student can show proof of alternate coverage.

One Metro State student said:

I will say that Metro should offer more options than one type of insurance plan. The students at Metro don’t fit into one age bracket. So where one ins. plan my be acceptable for some, it cannot fit the needs of such a diverse age group! I hope that Metro will change this ruling with their health insurance plan soon.  I know I have spent more time on the phone looking for a comparable ins. plan than anyone should have to!   There are better things to do with my time…. like STUDY for my classes so I will be able to get a better job that has fantastic insurance benefits.

Perhaps the school could add a higher deductible plan for students who understand the definition of insurance.

We contacted Martha Eaton, the head of Metro State’s Student health insurance office, to get her take on the waiver requirements:

The College waiver standards, which include minimum requirements for mental health coverage, have been established based on the demographic needs of our population over the years and the associated expenses for mental health services. Colleges throughout the country establish their own set of minimum waiver requirements for their particular institution, many of which are much more restrictive than Metro State’s minimum standards. As health care cost continue to escalate in the United States, it is more likely that colleges will raise their minimum standards, rather than lowering them. The importance of adequate mental health benefits cannot be underestimated, however, many individual insurance plans attempt to shortchange the consumer by inadequately providing either little or no mental health benefits. Individual insurance plans would be prudent to cover mental health care as they do all other medical conditions.

Ms. Eaton makes some good points, and we do recognize that not only is Metro State’s student health insurance policy better than many other student health insurance plans in Colorado, the overall requirements for a waiver are indeed lenient.  But because of the mental health benefit requirement, nearly all of the individual health insurance policy options in Colorado are eliminated as options for students at Metro State.   Ms. Eaton makes a valid point about mental health deserving as much consideration under health insurance policies as any other medical conditions. But as finance professor at CSU, Vickie Bajtelsmit, points out in her article “Don’t Insure The Small Stuff“:

A general rule of thumb for insurance is that you should never insure against losses you can easily budget for.

Individual health insurance policies in Colorado do not cover mental health as extensively as the Metro State policy for a reason.  Mental health isn’t something that typically turns catastrophic.  The reason for insurance is to protect yourself from catastrophic events.

The problem with the Metro State logic for the $10,000 minimum mental health coverage requirement is that they are saying they think $10,000 worth of mental health expenses is too much for students to handle.  Yet for conditions that pose a catastrophic risk, the Metro State health insurance policy appears to have a $10,000 out-of-pocket maximum (based on “Out of Pocket Limit” on Page 8 of the MSCD Brochure).  The following conditions seem to require the student to pay 20% after the $300 deductible until the student reaches their $10,000 Out-of-Pocket Limit:

• - Inpatient Room & Board and Hospital Miscellaneous Benefit
• - Inpatient Surgery
• - Outpatient Surgery
• - Physiotherapy (Physical Therapy)
• - Dental Treatment for an Accidental Injury
• - Durable Medical Equipment
• - Medical Emergency Room Services
• - Home Health Care
• - TMJ
  

Another risk to the students is because the Metro State health insurance policy is set up for students, the coverage will end once a student is no longer enrolled in classes.  If a student suffers a serious illness or injury while enrolled in the Metro State health insurance policy, he or she will likely have to seek guaranteed issue health insurance coverage once the student health insurance policy is no longer in force.  This would mean being limited to more expensive health insurance coverage through an employer-sponsored group plan, or Cover Colorado.

In addition, some students would prefer to choose a less expensive policy.  While the Metro State policy does provide a good value for students who can afford it, there are people who would rather buy an HSA qualified high deductible health plan, with good catastrophic coverage, but no bells and whistles. What would happen if I were to decide to obtain an additional degree at this point in my life?  I currently have an HSA qualified plan that perfectly meets my family’s needs, but does not have as much mental health coverage as Metro State requires (nor does it have the maternity coverage that CSU requires).  I would have to cancel my coverage and enroll in the Metro State plan or the Anthem Smart Sense plan.  This would be frustrating to say the least, and I would feel as if I were being treated like a child.

I can absolutely understand the position that colleges take when they require students to have health insurance.  And I would fully support requirements that students provide proof of some sort of “real” health insurance (as opposed to discount plans, accident supplements, cancer policies, etc.)  For students who don’t care one way or the other and are happy to have the college take care of their health insurance, the student health insurance plan is a good option.  But some students have done their own research and found an individual health insurance policy that better fits their needs and/or budget, and they would prefer to be given the option of keeping that policy instead.  For those students, we feel that colleges should reconsider their waiver requirements and treat their students as adults who are capable of making their own decisions.

Don’t get me wrong – I’m very much in support of organizations that focus on finding cures for medical conditions.  I’m thrilled that Obama is allowing federal funding for stem cell research, and I am glad that there are doctors and scientists who devote their lives to curing disease.  My own family hopes every day for an eventual cure for kidney failure that doesn’t involve a lifetime of immune-suppressing drugs, so that my father could be healthy again.  But when it comes to the lives of individual people who are battling illnesses, there are plenty of needs that are not met by the big disease advocacy organizations.

Cowboys Against Cancer, one of Jay’s parents’ favorite organizations, is an example of a group that is working to address immediate needs of cancer patients.  They are based in a small town, and raise money for local cancer patients to pay for expenses associated with travel to larger cities for cancer treatment.  I am impressed by the local focus and the organization’s efforts to tackle a pressing and immediate challenge facing cancer patients.

I think that the big disease advocacy groups that are focused on finding cures do provide an important service.  Raising money to find a cure is important in and of itself, and there’s also the camaraderie and support that organizations like this provide.  I participated in one of those walk/run events a few years ago in Denver, and it was obvious that it was a huge morale booster for the women (and men) who participated, especially those who were still going through treatment.  But Duncan’s article serves as a reminder that just donating money to a disease advocacy organization isn’t all that is needed.  And there are plenty of smaller, lesser-known organizations that are working to address other, more tangible needs that sick people face.

And while we’re on the topic of immediate needs, check out this article by Ill and Uninsured, about a 15 hour wait in a hospital emergency room.  The description of what it’s like to be in serious pain without health insurance is gut-wrenching.  The article raises so many issues:  under-staffing in emergency rooms, people who go to the ER with a sore throat because they don’t know where else to go, a lack of viable health care options for people without health insurance, and the patient perspective of what it’s like to be sick and try to navigate the health care system without health insurance.  Definitely worth a read.

I found these articles in this week’s Grand Rounds, hosted at Code Blog.

Ritter and Colorado lawmakers have been working on HB 1293 (the Colorado Healthcare Affordability Act) since mid 2008.  Although it’s rarely possible to please everyone with any new legislation, it does appear that HB 1293 has at least a measure of support from many sides, including most hospitals, the Colorado Association of Health Plans, and health insurers Anthem Blue Cross Blue Shield, Cigna, and United Healthcare.

The plan would involve charging a fee to Colorado hospitals which would generate about $600 million in revenue for the program.  That would then be matched by $600 million in federal funds.  The $1.2 billion generated will be used to expand Medicaid, the Colorado Indigent Care Program, and Children’s Health Plan Plus (CHP+), allowing more people to qualify for and enroll in the programs.

I like the approach of expanding current programs, rather than trying to re-invent the wheel.  All of the administrative systems are already in place for programs like Medicaid and CHP+.  Increasing the income limits and enrolling more people doesn’t require additional infrastructure or administrative changes.  Working within our current framework, but with expanded enrollment, seems to be an efficient way of going about this process.  It’s also probably the quickest way to actually get health insurance coverage to Colorado residents who need it.

There are currently 800,000 uninsured people in Colorado, so obviously this bill won’t solve all of our problems.  But it will be a start.  And hospitals like Denver Health, where a huge number of uninsured patients are treated, should find it a bit easier to stay afloat.

Check out the Grand Rounds at the Huffington Post HERE.

For anyone who thinks that our system will be fixed once we get health insurance for those who are currently uninsured, Dr. Rich’s article should be thought provoking.  Yes, being without health insurance in the US is a scary situation, and the sheer volume of people who are uninsured is a problem.  On an individual level, each person and family without health insurance is taking a significant risk – one that I’m sure most of them would rather avoid given feasible options.  But from a large perspective of the whole health care system, just providing health insurance to the uninsured would still leave us with a pretty big mess (not to mention the bill for that health insurance coverage).  We don’t have enough primary care docs, our drugs are too expensive, our hospitals are too focused on turning a profit, we spent more than any other country on our healthcare, and yet our results are mediocre at best.

Many thanks to Alvaro Fernandez at Sharp Brains, who hosted Grand Rounds this week, where I found Dr. Rich’s article.  The Colorado Health Insurance Insider article about the cost of treating the uninsured at Denver Health was included this week.  There’s lots of good medical reading, so head over and check it out.  And here’s hoping that Dr. Rich gets to spend Christmas dinner inside, at the table (although he might have to settle for the kids’ table unless he’s on his best behavior).

So I find it a bit hard to get my head around the notion that hospitals are adding perks like concierge service, gourmet room service, and cooking classes in an effort to attract privately insured patients.   Private health insurance reimburses at a higher rate than government-funded Medicare and Medicaid.  So hospitals compete with each other to get the privately insured patients.  And they claim that they’re adding the extra amenities in order to “… find any way possible to reduce the stress, reduce the tension, reduce the anxiety.”  According to Rick Wade, senior vice president of the American Hospital Association, that’s the motivation behind the push to add some posh to inpatient hospital stays.  I’m not buying that at all.  I think that hospitals are looking for avenues to boost revenue, and attracting a higher percentage of privately insured patients is a good way to go about it.  Of course gourmet food and concierge services don’t come free.  Somebody has to pay for all the bling, and the best way to do that is to increase what the hospital charges for care.  Of course the hospitals can then explain the extra charges to health insurance carriers as their efforts to reduce patient stress and anxiety.  It’s a convoluted circle, but however you look at it, the end result is higher health care costs.

While fancy suburban hospitals aimed at privately insured patients are adding beautiful atriums and high dollar artwork, hospitals like Denver Health are struggling to stay afloat.  Denver Health treats a large number of Colorado’s uninsured patients, and their cost for that care is expected to hit $350 million in 2009.  Hospitals like Denver Health are not on the list of places that are ramping up their glitz factor anytime soon.

I do understand the drive that hospitals have to increase revenue and attract privately insured patients.  But the focus should be on providing outstanding medical care rather than fancy extras that make a hospital stay seem a bit spa-like.  Adding non-essential services in hospitals that cater to well-to-do clients may make the hospital experience more enjoyable for those who can afford it.  But the unintended consequence is that as time goes on, fewer people will be able to afford health care at all.

Dr. Gabow has been working with Diana DeGette (D – Colo) and Nancy Pelosi to try to secure government assistance for treating the uninsured.  Otherwise, the hospital will be forced to cut services in order to make ends meet.  And for some of Denver’s worst hard-luck cases, that would be very bad news.  Denver Health is where people go when they have no place else to go.  It’s one of the only hospitals in the area with emergency beds for the mentally ill.  Without Denver Health providing this service, the local jail becomes the option of last resort.

Diana DeGette has been working in congress to try to get the federal government to provide more help to hospitals like Denver Health that take on a larger-than-average share of the costs of treating the uninsured population in the US.  Hopefully the new session that begins in January will address this issue, although finding money for projects like this in 2009 might be like getting blood from a stone.  The problem of paying for the treatment of uninsured patients is not a new one.  But as jobs disappear – along with benefits like health insurance – it’s likely that more and more people will be relying on hospitals like Denver Health.

The government does already provide some assistance, and in past years has paid as much as 30% of the costs associated with treating the uninsured at Denver Health.  But the costs have increased so much recently that the government share (not adjusted for inflation in over a decade) has dropped to about 20% of the total cost. That leaves a very big chunk of money that the hospital is losing by treating much of Denver’s uninsured population.

The common wisdom is that when hospitals have an increase in costs incurred from treating the uninsured, they eventually raise the rates that they charge insured patients in order to make up the difference.  But in a metro area like Denver, with multiple hospitals, ‘reasonable and customary’ charges are going to be determined by looking at charges from all of the area hospitals.  So even though a hospital like Denver Health treats more uninsured patients than other hospitals, they can’t charge health insurance companies higher rates to treat insured patients.  They still have to work within the guidelines established by reasonable and customary charges.  (I suppose they could charge whatever they wanted, but they would only get paid the amount that the health insurance companies deem appropriate).  For hospitals like Denver Health, government assistance is vital.  I don’t see a free market solution to this problem that doesn’t involve cutting off services to those without a means of paying.  And I hate to picture a United States where we turn the truly ill and injured away from our emergency rooms if they are unable to provide proof of health insurance.

I am paying COBRA, health and dental at $640. per month.
I am a nurse, recently diagnosed with cystic fibrosis (CF) at age 50, this year.
Cobra is 18 months with 11 month extension. I was informed I have to exhaust COBRA timeline before being eligible for Cover Colorado, the High Risk Pool.
CF is a respiratory illness that uses the same meds as any other respiratory disease. Nat’l Jewish sees patients a minimum of 4x per year, more if other symptoms occur as in diabetes.
Asthma patients use nebulizers just as CF pt’s do.
Tobramycin for pseudomonas is inhaled for CF pt, It’s an available medication. Therefore, if you have a non CF patient that has pseudomonas in their lungs, the treatment is the same. I don’t understand why CF has to be in the high risk pool. All other symptoms related would need to be treated at any other hospital. Additionally, CoverColorado is still more expensive for women/non smokers at age 50 than it is for men. We still make less in the workforce and have to pay more for health insurance. after age 50, women are nonchild bearing. So, why is there unequal costs. Also, CF at age 50 is definitely a shorter life span and I would probably need health insurance as long as 5-8 years. I’m paying for COBRA mostly because I need health insurance to “qualify” for future policies and exclusion waiting periods and in case I need it for non CF injuries/illness. I get my medications via the VA at no cost. Currently, I use Denver Health pharmacy or VA which lowers my out of pocket expenses. I think my insurance costs should be lower because of VA benefits. Would someone please address these concerns. Thank you so much. J.A., RN

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