What You Need to Know About Your Health Insurance Plan Choices

By Sarah Jio, Vitamin G, Glamour Magazine

It's a popular time of year for open enrollment--when companies allow you to pick your insurance plan and other benefits. Andrew Rubin, Vice President for Medical Center Clinical Affairs and Affiliates NYU Langone Medical Center, estimates that 25 percent of people don't even open their benefits book and just go with the default plan. But this year it's more important than ever to analyze your options. Here are a few things to know:
What's different this year?
Most employers have changed their plans this year due to the economy, say Rubin, and you'll have to foot a much larger portion of the bill. Health care costs have soared, and in flush times, employers have absorbed those increases. But when companies are choosing between layoffs or passing health care costs to employees, they often pick the latter (or both).

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What's the difference between an EPO and PPO and HMO?
It's worth nothing that all plans are different and depend on what benefits your employer has packaged together for you, but here's an overview: HMOs are typically the lowest overall cost option because the care is tightly managed and there are no out-of-network benefits, says Rubin. So if you have an HMO, but your doctor's not on the plan, you're stuck footing the entire bill. (Sometimes you will pay a little more out of your paycheck for an HMO than for a PPO because HMOs typically have lower copays, no deductibles or other savings.) An EPO is basically like an HMO, but it is open-referral, meaning you don't have to see your primary care doctor for a referral to, say, a podiatrist or other specialist if you need one. PPOs let you have some out-of-network care, so you can keep seeing any doctor--although it can still be expensive to do so. And some companies also offer high-deductible plans, which typically have very low premiums. If you're generally healthy, and paying a $5,000 or $10,000 deductible won't break you in an emergency, then these types of plans may be an option, say Rubin, "But if you can get into an HMO or PPO, I'd recommend it. High-deductible plans are risky, and you have to be able to stomach that. It's like going to Vegas--some people are comfortable in Vegas, and some aren't."

Shouldn't I just choose the cheapest one?
In a word, no, says Rubin. "Many employees only look at the rate sheets when choosing health insurance--and that's a mistake." You need to look over your last year's medical costs (ideally the last three years) to determine what is really the cheapest option for you. How many times did you go to the doctor? "If you utilize healthcare frequently, it is usually cheaper to select an 'enhanced' plan. Your premiums out of your paycheck are higher, but the out-of-pocket amounts you pay at the doctor are typically lower, so you save in the end," says Rubin. If you're a generally healthy, get-one-checkup-a-year kind of gal, you may want to go for a basic plan with a cheaper premium, and then just pay the extra copays or fees for that one visit. "Just remember, this is insurance, and you are protecting yourself from the risk of something bad happening--there are no guarantees. But this rule of thumb usually works," says Rubin.

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What is coinsurance, anyway?
For some people, this may be a new part of your benefits. "Coinsurance essentially says that you as an individual are responsible for a portion of the bill," says Rubin. Whereas in the past, you may have had to just fork over a copay and the rest of the visit was covered, if you now have a plan with coinsurance, you'll be required to pay for the copay plus a percentage of the rest of the cost. Those costs can really add up--especially if you go out-of-network.

Have more questions?
Check out rubinhealth.com. And remember, although benefit sheets can be intimidating, it's crucial to take the time to dive into the details. "You'll find it's not that complicated," says Rubin. "Just look at the plan with pen and paper, and figure out what you're utilization of services are. It could be the most important hour or two you'll spend all year."

Having Health Insurance Improves Control of Cardiovascular Disease and Diabetes

By Dr Cary Presant MD

It would seem obvious that having health insurance helps to provide better access to doctors and provide better treatments for serious illnesses. However, since many patients without health insurance can access urgent care clinics, emergency rooms, attend health clinics, and obtain primary care for cash, it is important to look at the impact of health insurance on control of important illness, and the relative impact of health insurance on different races and ethnicity.

In a recent analysis, Dr. J. M. McWilliams and his co-workers from Harvard Medical School (Annals of Internal Medicine, Volume 150, Page 505-515, 2009) looked at the control of blood pressure, high cholesterol and diabetes in patients with and without medical insurance from 1999 to 2006. In their study, the authors evaluated the results of the National Health and Nutrition Examination Survey which was conducted yearly between 1999 and 2006. This survey, called NHANES, was a nationally representative study given to individuals through interviews, physical examination, and clinical testing. Between 1999 and 2006, over 41,000 people were evaluated, of which over 12,000 were between the ages of 40 and 85 years. The authors then looked at how often blood pressure was normalized to under 140/90 and how often the hemoglobin level was normal (the hemoglobin A1C under 7.0), and how often cholesterol was controlled to a normal level of under 200.

The quality of care of all of these people improved significantly over the seven years for all of the measures that they were evaluating. These trends showed an improvement regardless of race, with the exception that Latino patients showed little improvement in diabetes care. For example the control of hypertension improved from 46% to 56%. The control of diabetes improved from 38% to 59%. The cholesterol level improved from 43% control to 63% control. Importantly, improvements were seen in each of the races, and improvements were seen in all socioeconomic categories. However, at the end of the treatment period, racial differences which had existed before were still present, although they were less pronounced. Black and Hispanic patients still had inferior control rates for diabetes, blood pressure and cholesterol.

When the control rates were evaluated for patients who were under the age which made them eligible for Medicare compared to older ages, it was apparent that individuals over age 66 had reduced the differences between race, indicating that the increased ability of Black and Hispanic individuals to have health insurance (Medicare) resulted in a reduction in their degree of poor control of high blood pressure, diabetes, and cholesterol.

This finding of improvements in control over the most serious health risks in Americans by availability of universal health coverage for individuals in the Medicare ages suggests that as a nation we can improve health by providing universal healthcare to United States residents. Since 50 million individuals in the United States lack health insurance, finding some method to make health insurance available to those individuals is important in increasing the prevention of serious health conditions, and minimizing utilization of healthcare resources because of uncontrolled health risks. In that regard, the recent expansion of the State Children’s Health Insurance Program will contribute to improved long-term care. Since there is currently a debate on healthcare reform, examples of the benefits of health insurance such as the studies of these authors should result in improved decision making by our representatives who will try to improve the quality of care for all Americans.

But let’s look at the news from this study in other terms. The good news is that as a nation, the control of our most serious health problems (hypertension, diabetes, high blood pressure) has improved dramatically. So what is the bad news? The rate of control is still very poor for a country that spends as much on health care as we do. I am shocked that less than 2/3 of people have satisfactory control of these illnesses.

So here are the take home messages for you this week. Always have health insurance, because control of serious illnesses is less without it. And even with or without health insurance, be sure your illness is controlled well: know the target lab test values and see your health care provider often enough to adjust your treatments until you are a winner, and your numbers are good, less than the quality target level!

Is Your Insurance Company Spending Too Much Money on Your Medical Care?

By Dr Cary Presant MD

We all know that medical care is expensive. Newspapers, television commentators, analysts and insurance spokespersons constantly remind us of this, as well as every employer and politician.

Some recent articles have extended the discussion about whether America is spending too much on treatments that are not producing the right health benefits. An article by Dr. F. Fowler, Jr., from the Foundation for Informed Medical Decision Making at the University of Massachusetts and his colleagues (Journal of the American Medical Association, Volume 299, Page 2406, 2008) along with commentary by Dr. G. Anderson and Dr. K. Chalkidou from Johns Hopkins School of Public Health (Journal of the American Medical Association, Volume 299, Page 2444, 2008) have asked how much the government spends on medical care and the patient’s perception about the quality of their medical care.

In the study, Dr. Fowler and his co-authors asked 4,000 Medicare patients, 65% of whom responded, about the quality of their care and the utilization of care, and compared their responses with the amount that Medicare actually spent on their medical services. They compared the lowest regions which spent $5,200 per patient per year with the highest regions which spent $8,500 per year.

The results showed some expected and some unexpected findings. The patients in the lowest spending area had fewer visits with the physicians (3.4 per year) compared to the highest area (3.9 per year), and the patients in the highest spending region saw more physicians (2.8 per year) compared to the lowest spending region (2.4 per year). The greatest differences were in the area of cardiac care (of course older patients more commonly die from heart disease than from any other cause). Only 23% of patients in the lowest spending region saw a cardiologist and the patients had fewer tests (40.1%), compared to the highest spending region, where 37% of patients saw a cardiologist and 64% had received a cardiac test. Despite this, and despite a higher utilization of specialists (3% in the lowest area versus 8% in the highest), the rating of their care as excellent was 63% in the lowest spending area compared to only 55% in the highest spending area! And in addition, patients in the lowest spending area saw their doctor less frequently!

As discussed by Drs. Anderson and Chalkidou, the outcomes of life expectancy and infant mortality have related more to education among women and average per capita income rather than the amount of spending per patient per year. Above a threshold of $2,000 per patient per year (for all patients, not just Medicare patients) there are a few improvements in outcomes compared to increased expenditures. Higher spending does not lead to increased health outcomes even in academic medical centers. And further, once patients have received explanations of all the risks and benefits of newer, more expensive treatments, patients do not always agree to more aggressive and comprehensive therapy.

Also of interest, is a report in the July 2008 Consumer Reports discussing the range of patient charges for care in various areas of the country. The 10 most “aggressive” medical centers included hospitals in New York City and Los Angeles, as well as Philadelphia, among others. The most conservative medical centers included hospitals in Texas, Utah, Wisconsin, Missouri, and Colorado. The health outcomes did not change compared to the degree of expenditures.

So what should we learn from these facts? First, you should NOT automatically conclude that your doctors are spending too much on your medical care. Your doctor is your best protection against too little medical care, and should be your best advocate against too much medical care. Therefore, we follow the recommendations of our primary care doctors and our specialists more than relying on the internet for guidance in care.

Even though the government might feel it is spending too much in your region, only your own doctor can advise you if you personally need more, or less care. So finding that right doctor who will put your needs above those of the insurance company is crucial to making the right decisions.

In order make certain that you are receiving, just like Goldilocks, not too much, not too little, but just the right amount of health care, you should follow these recommendations. You should know all about your physician through your physician’s website, and by knowing your physician’s reputation in the community. Your specialists should have good recommendations not only from your primary care physician, but also according other patients, and community organizations (such as the American Cancer Society or American Heart Association). Each of your physicians should always have earned your complete confidence (or else you should get a second opinion). You should always know about your hospital, and investigate its reputation in the community, its frequency of infections, its success rate in surgeries, and this data is available through your insurance company and national comparative websites.

You should also have frank discussions with your physician. Write down questions before you accept any kind of treatment. Do I need it? What will the doctor do differently if I have this test versus if I don’t? Will this test help me to live longer, or be more comfortable? What else do I need that you have not already ordered, and why would I need it? What are the benefits and what are the risks?

You should always ask your physician to coordinate your care with other physicians but you can help in this regard! Keep copies of your records from every physician including the notes from every office visit, and the results of all of your tests and x-rays. It is little additional work for the physician’s staff to make a copy for you that can be life saving if you visit another physician who might not have access to those results.

Have conferences with your doctor to discuss your diagnoses, treatment plans, expected outcomes, and risks. Make certain that prevention and screening has been stressed in these conversations.

Medicare has found that many doctors who own their own hospitals, laboratories, or radiology centers tend to overuse their own test and treatments, compared to doctors who do not own their own facilities. So be sure to ask your doctor or the office administrator is the doctor owns any facilities to which you are being referred. If so, you can inquire what other facilities can be sued, and whether the tests or treatments are really required. Sometimes a second opinion can help you decide.

Lastly, always have advanced directives prepared with your physician’s office, patient advocacy office in your hospital or insurance company, or with an attorney. Knowing what you want to have done in the event of serious illness which might not get better, and which might prevent you from making your own decisions, can only help you to avoid getting excessive treatments that you really don’t want, or guarantee that you will get treatments that you want despite the cost-saving preferences of your physician or your insurance plan.