Archive for August, 2011

Health Insurance, Meet the Jolly Green Giant

Trudy Lieberman
Wednesday, August 31st, 2011

It’s official now.  The government has proposed that descriptions of health insurance policies will resemble those nutritional labels on canned and packaged foods—the ones you look at to find out how much sodium there is in Birds Eye peas versus the A&P brand.  Instead of getting the scoop on salt or sugar, shoppers will learn what they have to pay out-of-pocket for various medical services.  They’ll also get some general information, like what services are not covered, and how much they’ll have to pay for maternity and diabetes care and breast cancer treatment, all organized in a standard format designed for easy comparison shopping.  Insurers will have to translate common insurance jargon into plain English.

The health reform law requires these “Coverage Fact Label” disclosures, and tasked the National Association of Insurance Commissioners (NAIC) with creating them.   The NAIC released some samples a few weeks ago.  Theoretically, consumers armed with this information will choose wisely, and as free-market advocates say, their choices will regulate prices that insurers will charge.   If consumers choose the low-cost plans, then prices will come down and policies with the best benefits will flourish.

Next March, consumers supposedly can get their hands on these labels.  But it won’t be so simple until 2014 when the reform law is fully effective, and the labels are required for state insurance exchanges.  Until then, says Washington and Lee law professor Tim Jost, the regulation says shoppers in the individual market will have to ask for them.  A company doesn’t have to provide the label, but must tell consumers they can find some policy information on a government website, healthcare.gov.  If you get insurance from an employer, the employer is required to produce the labels only when you first choose a health plan.  If you decide to switch plans at the next open enrollment period, your boss must provide a disclosure only for the plan you already have.  You’ll have to ask for the others.

The insurance industry, it seems, is not keen on providing this information, and insurers along with business groups are fighting hard to exempt large employers from the rules, arguing that the costs are too great. Robert Zirkelbach , a spokesman for the AHIP, the industry trade group,  says that since most large employers customize benefits packages this new requirement would mean that some plans would have to create tens of thousands of different labels.

Based on a long career reporting about consumer disclosures, my take on the labels is that they promise more than they can deliver.  Some of the information is useful, such as standardization of the definitions of deductibles and out-of-pocket limits, and copayments and coinsurance.   Consumers need to understand the difference between a copayment—a fixed dollar amount you pay for a particular service and coinsurance—a percentage of the actual bill you will pay. This is especially important since employers are moving away from small copayments to huge amounts of coinsurance that could really pinch the family budget.   There’s a big difference between paying 20 percent of a bill or 40 percent.   The amount of coinsurance could be a deciding factor in the choice of a policy.

But labels hardly tell the whole story.  What you don’t know and probably can’t find out is what the doctor charges for a service in the first place.  Those charges depend on the fees the health plan has negotiated with the doctor, which are deep, dark secrets.  Since the coinsurance is applied to those amounts, a plan with low coinsurance for a service with a high price tag may end up costing you more out of pocket than one with high coinsurance applied to a smaller bill.  Without that information, you can’t be absolutely sure one plan will be better than another when you really get sick.  Shopping for a policy and using it are two very different experiences.

Similarly, the examples of coverage and costs given for the three required conditions may be helpful for people needing maternity and diabetes care or breast cancer treatment, but not for others with different ailments.  Because one carrier discloses that it has a low price for breast cancer treatment doesn’t mean that price tags for gallbladder surgery or repairing a broken leg will also be low.  What’s to prevent an insurer from low-balling to reel in business for certain procedures and jacking up the prices for others?

In my experience, the usefulness of consumer information is often directly proportional to how much businesses scream about disclosures that can actually impact their business practices.  That’s why operators of bad nursing homes have hidden or made it difficult for the public to see their state inspection surveys, which they are required to post in a prominent place.  These reports show in detail how a home may be harming its residents.  And the banking industry finally succeeded in eviscerating the federal Truth-in-Lending Act, which standardized disclosures for the cost of credit and revealed to consumers what they were actually paying to  finance a purchase.

Only time will tell whether the Coverage Fact Labels will end up hidden away because they turn out to be effective at disclosing negative features of insurance policies, operate more like the Truth-in-Lending Act which is mostly meaningless or  resemble those nutrition fact panels that shoppers use only sporadically.

Middle-of-the-Night Medicine is Rarely Patient-Centred

Jessie Gruman
Wednesday, August 31st, 2011

It is all but a truism that the level of health care provided in hospitals on weekends or evenings isn’t on par with that provided on weekdays.

As Jessie Gruman, president of the Washington, DC-based nonprofit Center for Advancing Health says, “anybody who’s been in the hospital knows that it’s kind of banker’s hours after six o’clock. You feel really vulnerable if something happens at night because of the sparseness and responsiveness of the night staff.”

Hospitals are “just maintaining” after regular business hours, she says, adding that it’s not unusual for patients to wait several hours for diagnostic imaging tests because radiology departments are poorly staffed and other hospital staff are busy dealing with urgent care patients. “You’re just kind of sitting there in the hall in your blanket,” she says in describing her own experiences in receiving cancer treatment.

Read the rest of this report on the Canadian Medical Association Journal website….

Informed Consent & Doctor-Patient Communications in the News

Conversation Continues
Tuesday, August 30th, 2011

Conversation ContinuesConversation Continues feature ongoing discussions or news on current health topics with links to related materials.  They are part of the Center for Advancing Health’s portfolio of free, evidence-based coverage of what it takes to find good care and make the most of it. Written by Monica Kriete, CFAH Communications Associate.

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At the heart of the sensationalism surrounding a recent high-profile malpractice lawsuit are issues with the effectiveness of the informed consent process, concerns about general health literacy and problems with doctor-patient communications.

The case of Phillip Seaton, a Kentucky man who sued his surgeon after having a partial penile amputation, was covered extensively by the news media last week.  The Boston Globe reported that “Seaton’s attorney said during opening legal arguments that the surgeon hadn’t told his patient that the inflammation he planned to treat with a circumcision could be a sign of cancer and might necessitate the removal of Seaton’s sex organ.”

Seaton signed a consent form despite having limited literacy skills, raising questions about how the informed consent process commonly happens and how it could be enhanced.  There are some efforts being made to improve the informed consent process.   Scientific American in “Uninformed Consent: Tech Solutions for Faulty Permissions in Health Care” describes interactive computer programs that allow patients to pause, rewind and ask questions and may provide a more effective means of communicating the risks and outcomes of procedures and treatments.

Stephen Wilkins, in Poor Doctor-Patient Communication Is Closely Linked to Non-Adherence uses graphics to share a body of compelling research that points out that doctors tend to overestimate the amount of information they have conveyed to patients, while underestimating the amount of information their patients want.  This contributes to noncompliance and other sub-optimal patient outcomes.   As CFAH President Jessie Gruman wrote in her Prepared Patient post recently, “Most of us make [medical] choices with little guidance and support.” Doctors and patients need to work collaboratively to ensure that everyone is on the same page.

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Guest Blog: Recovery and Healing

Katherine Ellington
Monday, August 29th, 2011

Katherine Ellington is a medical student and writer. Her work has been featured in The New Physician magazine, at KevinMD.com and she blogs at World House Medicine. This post is the second in a three-part series; read the first post here and the second here.

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I had battled with mom the day before about going to the see her primary care physician or to the emergency room.  She instructed me drive her to her doctor’s office, but while there her chest pain became unbearable. “I really don’t want to go the hospital because they may keep me,” she lamented. I kept driving in silence.

Now, as I waited by her hospital bedside, she  opened her eyes only briefly, but she smiled. She was glad to see me.  She whispered, “I’m in the short-stay unit.  Does that mean my end is near?”  I laughed and said, “Oh no, that means you will be coming home soon, once you’ve recovered.”  She grimaced as she took in a breath that showed on her face and with a slight groan, she exhaled.  She whimpered. “The doctor did tell me that everything was fine now, but I just wanted to be sure they didn’t think I was heaven-bound.”

As a medical student, I’ve learned from my peers that parents are challenging as patients.  The reading available about this subject is sparse, but many physicians have told me an assortment of stories ranging from horrific to compassionate about caring for parents, partners, other family members and friends. My mom has at times invited me to come with her to doctor visits. On other occasions, I have insisted that I go with her.

In these situations, I’ve always identified myself as a physician-in-training. For the most part I’ve remained silent, observant and tense during these clinical encounters.  When I’ve interrupted, it has been to offer facts. I’m usually scolded by the patient and acknowledged as helpful by the clinician.  When Mom and I have debriefed after these visits, there are usually inconsistencies in our retellings. I point these out and ask her to follow-up if necessary.  Otherwise, we agree to disagree.

Time and experience have helped me find my role as a caregiver and advocate for mom. I focus on being her daughter.  I offer support with careful listening, trying my best to remain present.  My focus is on common sense advice with basic explanations about conditions and treatment plans, while urging follow-up conversations with clinicians and medical teams.  This much I can do and do well.

Once mom returned home from the hospital, we had almost daily conversations about medications. We reviewed symptoms that she should pay close attention to and talked through changes coming in the days ahead.  I was able to explain the significance of the procedure my mom would be having, but we were both familiar because my grandmother was in the same situation just a few years earlier.  Like my grandmother, Mom would have to take medicine, make dietary changes, and reduce the effects of stress in her life with physical activity and other changes.  I wouldn’t be there in person, but we could talk, text and Skype. She did her reading, talked with her doctor, prayed and set a plan for herself. 

I’ve learned that it is challenging to help patients understand that the healing process can be long and unpredictable.  Interventional catheterization, the procedure Mom underwent, is modern medicine at its best. While less physically traumatic than open heart surgery, it does require time for healing. It’s been a year now since mom’s procedure and her recovery has had some setbacks. Nonetheless, she’s made progress.

Recently, I found myself unable to take on my yearly challenge, to walk, jog, and run 100 miles in the weeks between Memorial Day Weekend and the 4th of July.  I felt overwhelmed and uninspired to get moving. It seemed too lonely. I needed a partner. When Mom overheard me telling a friend as much, she volunteered.  I was surprised and cautious.  We agreed to early morning walks at sunrise three days a week.  We’d each move at our own pace.

We decided to go to the park that I like sometimes, and at other times remain in our neighborhood. Our motivation and momentum continued with each week, to my surprise. I’m jogging more and Mom’s complaining less about incline of the hill on the path. We’re averaging about 45 minutes, 3 days a week, together.  On the drive home, we do chat about travels to places we’d like to visit. Mom’s healing and so is our relationship, and this has added to my life as well as my medical school experience.

I’ve been told to treat patients as if they were my mother, to offer competent care with empathy and compassion during clinical encounters.

But it’s become all too obvious to me that it’s complicated when a patient is a loved one. Health care professionals and their patients need help in navigating these situations, especially within real communities where people work, live and play together. In the working and lately in the playing together, Mom and I both are steadily healing and learning together.

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