In Carroll’s article, she described a meeting of the Health Care Task Force where the practice of gender-based pricing in health insurance was debated.  I am amazed by the comment from Rep. Jim Kerr, who explained that “women like to shop” and we should thus do a better job of shopping for our health insurance.  And by the health insurance underwriter (a male) who said we should “blame God” for the fact that women’s parts are on the inside and men’s parts are on the outside.  Seriously?  Those comments alone make me hope for gender equality in health insurance just so that we can stop having this discussion.

Senator Carroll also noted in her article that in the individual health insurance market “the rates are already significantly higher than in the small or large group market.”  This isn’t correct – in fact, the opposite is true.  In most states, including Colorado, group health insurance premiums are more expensive than individual premiums.  This is because individual plans can exclude pre-existing conditions or decline applicants with serious health issues.  In addition, group plans have more state mandated coverage (like maternity) than individual policies.  For my own family, a group health insurance plan would be twice as expensive as our individual plan (even for a policy with much higher out of pocket exposure).

It’s a common misperception that group policies are less expensive than individual policies, likely because employers pay a chunk of the group policy premium, masking the true cost of the employee’s health insurance.  The amount that is taken out of an employee’s check is not the actual cost of the health insurance.

Ideally I’d like to see homebirth midwifery legalized and regulated in every state (there are currently 12 states where it is illegal to practice as a home birth midwife).  I’d also like to see it become a recognized covered expense on any health insurance policy that covers maternity (which includes all group policies, but very few individual policies).  In Colorado, home birth midwifery is legal and regulated, but midwives still have to jump through a lot of hoops to get paid on the rare occasions when their clients’ health insurance policies cover home birth expenses.

I know that physicians tend to balk at the idea of home births.  And since the only home births they come in contact with are the ones that go wrong and require a transport to the hospital, I guess it’s reasonable that they would feel this way.  Hopefully this study will help them to recognize home births as a safe alternative for low risk pregnancies.  Of course there is a bit of a turf war involved in the stance on home birth taken by groups like ACOG and the AMA.  And as far as that goes, studies that show the safety of home births aren’t likely to have much impact.

For the last two months of her pregnancy, my friend had weekly ultrasounds, and did more than her fair share of worrying.  When the baby was born, he was immediately taken from his parents and transferred to the NICU, where he was subjected to a range of tests.  He was not allowed to nurse for the first 24 hours after he was born.

Turns out that he’s perfectly healthy.  There are no issues with his intestines, and he was discharged from the hospital without surgery or the two week NICU stay that my friend had been expecting.

I was reminded of my friend’s story when I read this article by Marya at Healthcare etc.  Was my friend’s doctor practicing defensive medicine?  Probably.  Was she just trained to see problems, and thus spotted one that turned out to be nothing?  Whatever happened, it absolutely had an impact on the healthcare costs associated with my friend’s pregnancy and birth.  Eight extra ultrasounds and 24 hours of testing and monitoring in the NICU are not cheap.  She hasn’t seen the EOBs from her health insurance company yet, but I’m sure that the cost ended up being significantly more than it would be been without the looming fear of problems that hung over the last two months of the pregnancy. Luckily my friend has health insurance, so she won’t end up paying directly for the extra care.  But all of us pay for stuff like this in the form of higher premiums.

I found Marya’s article in last week’s technology-themed Grand Rounds, hosted at Medicine and Technology.

Now we just have to get ACOG on board too.  C-section rates in the US are far higher than the World Health Organization recommends, and women here who have a breech baby are routinely herded into the OR, with little choice in the matter.  Jay was born breech, and so was his sister.  Neither was a c-section, and both turned out great (you can pay me later, Jay).  Obviously those are just two incidents (and we all know that anecdotes are not data) but had Jay and his sister been born 30 years later than they were, Jay’s mother would have been subjected to two major abdominal surgeries – which also involve risk - that she didn’t really need.

In the current quest to reform health care, everyone is talking about controlling costs.  Lowering the rate of c-sections would have a significant impact on the cost of maternity care, since vaginal births are much less expensive than surgical births.  Maternity care is something that most women eventually use, and lowered costs would translate to lowered health insurance premiums for all of us.  I have friends here in Colorado who have been subjected to routine c-sections because their babies were breech, and in one case the parents ended up paying several thousand dollars out of pocket for the birth, since the surgery was done at an out-of-network hospital.  A change in protocol for breech births seems like it would benefit mothers, babies, and health insurance companies (and all of us who pay premiums for insurance).  Let’s hope that ACOG follows in SOGC’s footsteps.

I found Amy’s article in Grand Rounds last week, hosted at Florence dot com.

The point is, there really is no one-size-fits-all when it comes to health insurance.  In terms of health care reform, unless someone just starts handing out free health care (without tax increases or premiums…), it will be tough to get people to agree on a single plan, or even a handful of coverage options.

Each state has its own regulations in terms of what all policies in that state have to cover.  The rules are different for group and individual health insurance.  In Colorado, for example, all policies have to cover well-child care, PSA testing and mammograms (based on age).  All group plans have to cover maternity, but individual plans do not.  There are a handful of individual carriers in Colorado that do offer maternity as an optional benefit (Assurant, United HealthOne, and Rocky Mountain Health Plans) but the majority of individual plans do not.  This is because the state doesn’t require it, and the market won’t support it (the premiums are expensive, and very few people choose to pay the extra premiums for maternity care on individual health insurance policies).

For people who get their health insurance coverage from their employer, there aren’t likely to be a lot of choices in coverage, but the employer is probably subsidizing a good chunk of the premiums, which makes it easier to accept whatever is offered.  For people buying health insurance in the individual market, there are lots of options, but pricing and medical underwriting can often limit the choices.

Bill Kramer has written an article about the issues involved in designing a national benefit plan.  Overall, the process and compromises involved sound a lot like what goes into designing private health insurance policies: a delicate balance between cost and coverage, targeting the widest consumer group possible.  The major advantage that the private health insurance market has in this regard is that it can implement a wide range of options, with policies ranging from bare-bones catastrophic coverage to very comprehensive “gold-plated” coverage.

If health care reform ends up involving a public, national health insurance option, it would be wise for them to offer multiple plan designs in order to give people choices in terms of premiums and coverage.  Otherwise, it’s unlikely to appeal to a large number of people.

I found Bill’s article in the Health Wonk Review, hosted this week at Health Care Policy and Marketplace Review, written by Robert Laszewski.

A friend of mine who lives in a smallish Colorado town had a c-section with her first baby after 45 hours of labor.  She wanted to try for a VBAC with baby number two, but was told that she would have to go to Denver a month before her due date and stay near one of the big metro hospitals until she gave birth.  Between her job and taking care of her toddler, that wasn’t a particularly viable option, and so she had a repeat c-section.  In fact, several of my friends had c-sections with their first babies, and all have gone on to have repeat c-sections.  They were all warned ominously that they could suffer uterine rupture if they opted for a VBAC, but none of them mentioned anything about the issues that Kathy raised in her article.

United HealthOne has changed the way they underwrite applicants in Colorado who have had a c-section.  They now charge an additional 30% on top of the standard premiums in these cases.  All health insurance carriers in Colorado cover “complications of pregnancy”, but most of them do not consider c-sections to be complications.  United does consider c-sections to be complications, but only if they are emergency c-sections (ie, not scheduled).  Since most OBs schedule repeat c-sections, it’s rare that a woman would end up with an unplanned, emergency repeat c-section.  So I was a bit perplexed by the new underwriting actions.  But after reading Kathy’s article and learning about the problems that can occur in a subsequent pregnancy following a c-section, it makes more sense.

I found Kathy’s article in the Cavalcade of Risk, hosted last week at Healthcare Manumission.

If you’re up for a little controversy, PalMD at White Coat Underground has written about conscience clauses that allow medical providers to refuse to to provide care if it conflicts with their personal beliefs.  Read the article and then scroll through the comments to see lots of different view points on this issue.  A very good point raised is that the conscience clauses tend to be invoked in matters of reproductive health.  And overwhelmingly it ends up being women’s reproductive health issues that are impacted.  Here in Colorado, a similar issue was raised last year concerning the sale of two Exempla hospitals to a Catholic organization.  It’s a touchy subject with both sides 100% convinced that their own arguments are the only valid ones.  And that makes for an interesting article and interesting comments.  Since this is my article, I’ll weigh in with my own opinion:  If you have a job that entails serving the general public (who have a wide range of beliefs that may be far different from your own) and your conscience prevents you from doing your job, you might be in the wrong profession.

I’ve written about this topic too, and overall, I will say that I agree with Bob.  Enough people are already crying uncle when it comes to health insurance premium increases.  Every time we add a new treatment to the list of things that health insurance companies are required to cover, premiums go up.  As premiums increase, more people find themselves unable to afford coverage.

But that said, I don’t think that the comparison between hair transplants and infertility treatment is completely fair.  I do see the general connection.  But hair loss happens to most men (and some women) eventually.  It’s part of the aging process, and doesn’t really indicate that anything is physically wrong with the person.  In a similar fashion, infertility happens to all women eventually, in the form of menopause.   A person with unexplained hair loss at 25 might have a physical condition that goes beyond normal hair loss related to aging.  In that case, it would be reasonable to expect the person to seek answers.  And the same can be said for people who are experiencing infertility years before the onset of menopause.

Infertility is a medical condition.  If you’ve been through it yourself or are close to someone who’s been through it, you know the heartache that it causes.  For a little more reading on the subject, there are lots of blogs that document the long and winding road of infertility.  In an ideal world, people wouldn’t have to shell out tens of thousands of dollars for infertility treatments.  But without some form of subsidization for health insurance premiums, it’s not realistic to add infertility treatment to the list of conditions that health insurance covers.  Although I would add that it probably feels like a slap in the face to infertile couples who are paying their own way through IUIs and IVFs to know that erectile dysfunction is covered by health insurance.

One of the often-overlooked benefits of health insurance is the negotiated fee schedules that are worked out between providers and health insurance carriers.   When claims are considered “covered expenses” the billed amount is almost always reduced because of network negotiated pricing discounts.  Unfortunately, infertility treatments aren’t covered expenses and don’t get repriced by health insurance networks.  Couples seeking help with infertility use credit cards, home refinancing, private loans, and life savings in order to pay the bill.  They may be able to work out deals with the clinic, or secure a great financing program – but at the end of the day, they’re on their own to pay the bill.

I agree completely with Bob’s position on low-cost treatments and health insurance: “if the cost of a “semen analysis” is reasonably low, why do we need insurance to cover the cost?“  Covering low-cost treatment doesn’t fit the definition of insurance anyway.  But for a lot of couples dealing with infertility, the semen analysis is just the beginning.

I found Bob’s article in last week’s Grand Rounds, which was hosted at In Sickness And In Health.  Barbara did a great job of putting everything together and throwing in a little sci-fi nostalgia along the way.  The Colorado Health Insurance Insider article about the nationwide nursing shortage was included in GR – thanks for hosting, Barbara!

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.

• average premiums for individuals: $158/month (up from $148 in 2006)
• average premiums for families: $366/month
• average individual deductible: $1972
• average family deductible: $2610

If we look at the detailed findings of the study, Colorado has average premiums below the national rate, at $141/month for an individual.  The high end of the scale mentioned in the article is for states like NY that don’t allow medical underwriting on individual health insurance policies.  The result is that everyone gets covered, but everyone pays more.  Colorado has laws regarding individual health insurance that are very similar to most other states – medical underwriting is permitted, and premiums can be based on health history.  My own family has a health insurance policy with an annual premium of $5976, and a deductible of $3000 (unfortunately both a bit higher than the average found in the study).  But it’s still a lot better than paying $12,000/year for a group policy.

While this study does make the individual health insurance market seem pretty rosy, there are a few issues that deserve a mention.  Although a huge number of policies were sampled, the nature of the research meant that the policies had to be issued and in force in order to be included in the study.  So only people who were healthy enough to be issued policies in the individual health insurance market were included (plus those in a few states like NY where individual policies are guaranteed issue).  The results obviously don’t include those who were declined or had to obtain coverage through a state high risk pool (typically a much more expensive option).  So while the individual health insurance market is great for healthy people looking for an affordable option for health insurance, the options are limited or non-existent for a lot of people with serious pre-existing health conditions.

The other issue is coverage.  A deductible of $1972 for an individual and $2610 for a family might seem pretty high to people who are used to comprehensive group health insurance coverage.  Deductibles have been steadily creeping up on group policies as employers seek to curb costs, but these numbers are still higher than most people are accustomed to.  Maternity care is another factor that might catch a lot of people by surprise in the transition to individual health insurance.  Maternity is one part of a group health insurance policy that a lot of women plan to use, as opposed to most parts of our coverage that we hope we never need.  But in the individual health insurance market, maternity coverage is hard to find.  Here in Colorado, there are only three carriers – Rocky Mountain Health Plans, Assurant, and Golden Rule/United Healthcare – that offer maternity coverage at all.

So while the numbers in this study do indicate that individual health insurance is a relatively affordable option, there’s still a whole group of people who are uninsurable in the individual market because of their health history.  And the trade off with an individual health insurance policy is that your out of pocket expenses might be higher than you’re used to.  But the upside is that if you’re healthy there are plenty of affordable options available, and in the event of a serious health problem, an individual health insurance policy will protect your assets.  Which is why we have health insurance in the first place.