One of the major aspects of health care reform that has gained a lot of traction this year involves doing away with medical underwriting on individual health insurance policies, and would require health insurance carriers to accept all applicants, regardless of health history.  Obesity is considered a pre-existing condition by all of the individual health insurance carriers in Colorado.  Obviously applying these standards to a healthy, breastfeeding baby is ill advised, but I believe it makes sense for adults.

The guidelines are currently pretty lenient when it comes to weight.  Most carriers start to increase the premiums on their policies if an applicant has a BMI of around 30 – which is the cutoff for obesity, according to the CDC.  Being overweight, but not obese (BMI of 25 to 29.9) doesn’t result in a rate increase at all with many carriers.  So a 5′5″ female can weigh up to 180 pounds and still qualify for a standard rate with many of the individual health insurance carriers in Colorado, assuming she is a non-smoker and doesn’t have any other pre-existing conditions.

I’m curious to see what happens to underwriting regarding obesity and tobacco use as health care reform moves forward.  Both of these factors are known to increase health care costs.  They’re also factors that each person can control – not saying that it’s easy, but it can be done.  I can see the benefit to making sure that everyone gets accepted for health insurance, regardless of weight, as it’s counterproductive for society as a whole to have people who are uninsured.  But I believe that it makes sense for obese applicants, and tobacco users, to pay more for their health insurance in order to offset the higher claims they are statistically likely to have.

I’m curious to hear what our readers think about this topic.  Should obese applicants pay more for their health insurance than normal weight applicants?  What about smokers?  Does this amount to something akin to a regressive tax, since lower income people are more likely to be overweight, and also more likely to be smokers?  Should income then be taken into consideration when setting health insurance premiums?

Cover Colorado is a reasonably-priced alternative for people who aren’t eligible for private health insurance.  It’s also available for those who have been offered a private policy with a rate higher than Cover Colorado’s, or with an exclusion on a particular pre-existing condition.  But this basically means that the insureds in the Cover Colorado system tend to be some of the state’s sickest residents.  Group health plans also have plenty of sick people (since group policies have to accept all eligible employees of an insured business, regardless of health), but they also have lots of healthy people.  Since Cover Colorado basically requires that an applicant have pre-existing conditions, their claims to premium ratio is understandably high.

An article in the Denver Post yesterday indicated that perhaps someday Cover Colorado will expand their eligibility.  Apparently it is being discussed as a possibility, although funding is the major hurdle.  The most obvious benefit would be the rise in premium revenue that would be collected if more people were to join the pool – and if those people were healthy, the premiums to claims ratio could be expected to improve over time.

It wouldn’t be fair to expect private health insurance companies to continue to subsidize the Cover Colorado program at the current levels if healthy people were allowed to join, but perhaps the increased premium revenue would make up the difference.

I’m glad that we have Cover Colorado as an option here, and I’m well aware that there are states where people who don’t qualify for private health insurance have no option at all.  But there are some eligibility guidelines for Cover Colorado that still end up leaving people uninsured or under-insured.  The six month residency requirement is a tough one, and it’s only waived for people who are moving from another state’s high risk pool.  People who are coming off of a group health insurance policy in another state (and who are unable to qualify for a private individual policy) have to live here for six months – uninsured – before they qualify for Cover Colorado.  In addition, a person who is eligible for any group health insurance policy – regardless of how bad the coverage might be – is not eligible for Cover Colorado.

My vote would be for relaxing both of these guidelines.  That would no doubt increase the number of sick people enrolling in the program, but it would also help to expand health insurance coverage and access to health care to more people, which should be the ultimate goal.  In order to make up for the additional losses created by enrolling more high-claims people in Cover Colorado, perhaps eligibility could be expanded to include some of the state’s healthy – but currently uninsured – population.  Obviously the premiums are the major issue here (Cover Colorado is currently more expensive than private health insurance), but I’m glad to see that people are considering this as a possibility for insuring Colorado’s uninsureds.

There isn’t likely to be any one solution that will insure all 800,000 Colorado residents who currently are without health insurance.  But perhaps expanded eligibility for Cover Colorado might be part of the solution.

Now, an insurance company called GuideOne Mutual actually had a question about “religious denomination.” And it seems that Atheists and Agnostics were charged more.

The Department of Justice sued GuideOne in federal court in Kentucky after receiving complaints about the insurer’s “FaithGuard” policy that offered homebuyers, owners and renters in 19 states special benefits and discounts if they were churchgoers.

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.

Then there are five questions:

- Are you concerned about the rising cost of doctor and hospital services? (yes or no)

- Are you currently covered under a medical insurance plan? (yes or no)

- In terms of hospital and medical coverage, how would you rate your policy? (good, moderate, poor)

- Does your present policy help pay for outpatient expenses such as doctor office calls, X-Rays, EKGs, Chiropractor Office Calls, Outpatient Hospital Services, and Preventive Care? (yes or no)

- If the cost were reasonable would you be interested in a hospitalization and surgical insurance plan that can also provide optional outpatient coverage that is now available to small business owners, individuals and retirees, as well as rural co-operative members? (very interested, interested, somewhat interested)

Below that is a place for the respondant to fill in a name, address and phone number.  And at the bottom of the page is a disclaimer: “This insurance plan is independent of and not affiliated, associated or endorsed by any national electric assocation or any local Farmers, Electric, Telephone or other rural co-operative.  This insurance plan is individually underwritten by Reserve National Insurance Company.  A Company agent may contact you with details about benefits, costs, limitations, exclusions and renewability.”

Ok, now it makes sense.  It’s a direct mail marketing campaign for Reserve National Insurance Company.  A quick search on Google turns up a website for the company.  It’s a pretty standard insurance company website, except that the products tab only provides a brief overview of the plans available, with no links to plan details.  So I wasn’t able to get a good idea of what sort of coverage the policies actually offer.  I did see that the company is rated A- by A.M. Best, and has been in business for more than 50 years.  I was also able to see lots of details about the agents and area managers (including a local one in Colorado) on the company website.

I have no problem with direct mail marketing, or with marketing in general.  I know that companies have to advertise and attract clients in order to stay in business.  But I did find the particular style of this marketing campaign to be a bit disingenuous.  Why is there a reference to co-ops on the front of the envelope?  Given the disclaimer at the bottom of the letter, I’m a bit confused as to why co-ops were even mentioned at all.  Is it because health insurance co-ops have been in the news lately?  Is it because co-ops give people a feeling that they’re getting a good deal?  Who knows.

Basically, the questionnaire is just a lead generating mechanism.  That is clearly stated at the bottom of the letter, when it says that “a company agent may contact you“.  Again, I have no problem with marketing, but I much prefer lead generating campaigns that are clear in their intent.

Tom Emswiler’s article highlights the obvious problem – the fact that the number of scans jumped by such an astounding amount following the clinic’s acquisition of a scanner – and also details the physical risk posed to patients when unnecessary scans are ordered.  When my father was hospitalized a few years ago with serious peritonitis, several CT scans were done.  My family – and his doctors – agonized about the radiation exposure from the scans, but he was in a life or death situation at the time, and the risk of the scans seemed worth it.  The idea that any doctor would order more scans with personal financial gain in mind is unfathomable to me.

I like Tom’s idea for reimbursing physicians a set amount, regardless of what type of imaging is ordered.  Although the flip side there is that an unscrupulous doctor might choose to skimp on care in order to pocket the extra money.  I suppose there will always be doctors who put their own financial interests ahead of their patients’ needs – but I like to believe that they are a small minority.

Overall, it makes sense to pay doctors based on patient outcomes and evidence based medicine, rather than paying them for each specific procedure.  And after reading the article about the clinic that bought its own CT scanner, I think we need a clear delineation between the people who order expensive testing for patients, and the people who earn a living from performing such testing.  If the doctor owns the testing equipment, and also orders the tests, there isn’t a good way to eliminate conflicts of interest.  In cases like this, we need health insurance companies that deny claims.  But it’s hard to explain to patients that the health insurer is actually the good cop in that circumstance, working to keep health care costs in check.  The patients have a relationship with the doctor – not with the health insurance company – and when the doctor says an expensive test is needed, the patients tend to trust the doctor.  What they might not know is how much more money the doctor stands to earn if the test is completed.

I found Tom’s article in the Health Wonk Review, hosted last week by Jaan Sidorov at the Disease Management Care Blog.

I agree that health insurance does need some reform.  Pre-existing conditions is a major issue that needs to be addressed.  For people without access to employer-sponsored health insurance, pre-existing conditions can significantly limit the number of policy options available.  And in some states (those that don’t have a Cover Colorado-style high risk pool), there aren’t any options at all.  Issues like this need to be addressed, and people need to have access to affordable health insurance, regardless of their medical history or job status.

But reforming health insurance without reforming all of the other aspects of our health care system isn’t going to get us far.  Making changes to who pays for the care without addressing the underlying cost-driving issues within the care system itself won’t help in the long run.  If we still have drug advertising (to consumers and doctors alike), the use of perscription medications will continue to rise (along with the cost burden this places on the health care system).  If we still have specialists who are paid twice as much as primary care physicians, we’ll still have a shortage of primary care docs, and too many people going directly to higher-price specialists for care.  If we don’t make participation in paying for the health care system mandatory, we’ll still have people who choose to not enroll in coverage, creating an additional burden on those who do.

And the list goes on.  There are many aspects of the health care system that need to be addressed if we want to lower costs and provide genuine access to health care for all Americans.  Health insurance reform is part of the puzzle, but it’s not synonymous with health care reform.

One thing that caught my eye in her article was her description of trying to schedule a pap, finding a timeframe that would work for her, and then finding out that it was 2 weeks earlier in the year than her last pap had been, and thus would not be covered by her health insurance if she went ahead with that appointment date.  So she’s putting off the visit until she can fit it in.  She’s self employed, and taking time off work to go to the doctor makes a dent in her income.  I know how she feels.  I’ve had the same situation arise when I tried to schedule a dental cleaning (back when I had dental insurance), and also when I tried to schedule a well child check for our son.  I know that wellness checks are designed to adhere to a specific schedule, and obviously health insurance (and dental insurance) companies don’t want to be paying for extra visits.  But a little flexibility would go a long way.  How about letting people schedule annual exams anytime within a one month window of when their prior exam was?  Or even a couple weeks would help.  It would be better than having people put off exams because of scheduling conflicts, and then forgetting to reschedule them.

Glenna’s article sheds light on what most of us (not just women) want when it comes to health care reform.  We want something that is well-thought-out, focused on what works best for patients and health care professionals alike, and with a minimum of political grandstanding.

I found Glenna’s article in Grand Rounds, hosted this week by Kim at Emergiblog.

I tend to agree with Zach, but I can see some issues that people might raise to counter his arguments.  First, a car isn’t essential to life, but a healthy body is.  It’s feasible for a person to spend an entire lifetime without a car (and thus without paying for car insurance).  But there is a physical body carrying each of us around every day, and we can’t just choose to do without it.  That said, it is possible to go a lifetime without receiving health care and still be quite healthy.  There are people in remote corners of the world who do just that.  Of course they are the exception, rather than the rule.  But so are Americans without cars.  So while people will raise the argument that car insurance isn’t essential (because some people don’t have cars) while health insurance is, I agree… but this is a moot point for the vast majority of Americans, given that most of us have cars, and thus a need for car insurance.

Another issue is the lifespan of a car.  Personally, I drive a car that was manufactured before most of America knew who Bill Clinton was.  But that makes me the exception to the rule as well.  Most people don’t keep cars anywhere near that long.  As a country, we tend to buy a car, keep it and maintain it for several years, and then trade it in for a newer model.  We have car insurance to protect our assets in the event of an accident, but we expect a certain amount of outlay in the form of car payments and maintenance that we’ll have to shell out ourselves.  And we tend to trade in our vehicles long before they need serious repairs.  We don’t have this option with our bodies.  We only get one, and it has to see us through for the long haul.  If we abuse it or neglect it or get tired of it, we can’t trade it in for a newer model.  So while maintenance and basic care is important for a car, it’s essential for a healthy human being.  And as time goes by – especially when people have been less than diligent at the basic maintenance – the repairs and tune ups for humans get a lot more expensive.

Car insurance companies are making a profit.  They base rates on individual characteristics like age, gender, and driving history.  They deny policies to people who have an unacceptable risk history.  And although some people choose to not have a car and skip car insurance all together, the vast majority of Americans continue to drive, and to have a need for car insurance.  In Colorado, if a person chooses to go without health insurance and then ends up with a catastrophic medical bill, bankruptcy will be the likely outcome.  Same story for a person who chooses to drive without car insurance and then causes a serious accident, except that the person driving without car insurance will also be facing legal action for making that choice (in Colorado, all drivers are required to carry liability auto insurance, but health insurance is not mandated by law).

Health care elicits a far more emotional response in people.  People who consider it perfectly acceptable for car insurance companies to cover only catastrophic, future (ie, not pre-existing) events find it deplorable when health insurance companies use the same model.  Same goes for basing rates on factors like personal history, age, and gender.  And when it comes to car insurance, we’re all on a somewhat level playing field, as it doesn’t tend to be a job-related benefit.

I find the car insurance/health insurance comparisons interesting, and am curious to see what our readers think about this topic.