The Doctor Weighs In

By MICHAEL L. MILLENSON

The American Medical Association has now added a second pillar to its national health care reform plan. The first pillar, of course, has always been “Don’t sue,” a sturdy principle that over the decades has led the AMA to alliances with such notable victims of overzealous attorneys as tobacco companies. (For historical perspective, see Howard Wolinsky and Tom Brune’s 1994 book, The Serpent on the Staff.)

The second health reform pillar, it has now become clear, is: “Pay what’s due,” shorthand for “Give us what we ask for, and do it quickly.” This is also consonant with deeply held AMA beliefs.

A newly released study commissioned by the association found that insurance company bureaucracy and a “chaotic” claims process is draining time from patient care, diverting as much as 14 percent of physician revenue and costing “as much as $210 billion annually, without creating value.” Claims payment must be made “cost-effective and transparent,” the AMA asserts. And what could be more cost-effective than quickly writing a check for whatever the doctor asks for?

While I’m all in favor of cost-effectiveness and transparency, the AMA study does seem a tad harsh. Surely, one of the thousands of claims-processing cubicle dwellers corralled into windowless buildings on bucolic insurance company campuses must occasionally uncover an honest mistake or two in coding? As we know, even doctors’ office staffs aren’t perfect.

Although the AMA study found large variation in how quickly insurers paid, the problem of variation among doctors went unaddressed. Frankly, some are non-compliant, refusing to follow insurer instructions despite repeated phone counseling by highly trained high-school graduates. Alas, no insurance executive attempted to explain-away poor claims-processing marks by proclaiming, “My doctors are different.”

But what’s really shocking about the AMA study is that $210 billion figure. While at first glance it seems to draw on a methodology known as “throw in the kitchen sink,” I realized it actually fit quite well with a separate examination of health system bureaucracy. With a little searching, I found it:

“Because the U.S. does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented…With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.”

That analysis comes from Physicians for a National Health Program (PNHP), long-time flag-wavers for a Canadian-style single-payer system. As for the costs imposed by lawsuits, most Canadian doctors “receive malpractice protection from the Canadian Medical Protective Association, which tracks the number of legal actions launched and the amounts paid out to successful cases,“ according to the Canadian Health Services Research Foundation. Since 1995, the foundation added, there has been a steady and “startling” drop in the number of lawsuits filed and a steady increase in judgments favoring doctors in those lawsuits that do go to trial.

As it happens, there is a calculation of wasted dollars that dwarfs either the PNHP or AMA numbers, but it has nothing to do with paperwork. A 2005 Medical Care study by Terry S. Field et al. (Medical Care 43(12):1171-1176) examined annual costs related to adverse drug events in the ambulatory setting.
It concluded: “Across the entire population of Medicare enrollees age 65 and older in 2000, we estimate the annual cost for adverse drug events occurring in the ambulatory setting was more than $2 billion, of which $887 million was associated with preventable adverse drug events.”

The authors did not suggest report cards to help patients pick the safest doctor. But the methodology does suggest that one AMA concern was addressed.  Since the study was done at a large HMO, at least the doctors didn’t have to worry about getting paid.

Brian Klepper

A detailed new study from the Economics Policy Institute confirms what many of us suspect but haven't had the data to easily nail down. This weightily-titled report by Jared Bernstein and Heidi Shierholz - A Decade of Decline: The Erosion of Employer-Provided Health Care in the United States and California, 1995-2006 - provides more granular information about the enrollment dynamics over time in employer-sponsored health coverage than we've seen in a while. Based on an analysis of the March 2007 Current Population Survey, the numbers reported here are mostly in sync with (but deeper than) similar studies that have attempted to size the enrollment and erosion characteristics of the employer-sponsored coverage market. Strap yourself in; this isn't pretty.

There are two important points here. The first is that, in the six years between 2000-2006, the percentage of American workers with employer-sponsored coverage fell from 51.1 to 48.8 percent, a 2.3 percent absolute or 4.5 percent relative drop. 6.4 million workers (and presumably, another 7.6 million of their family members) lost their health coverage in the process. These losses exceeded gains made between 1995-2000, when the percentage of workers with coverage rose from 49.6 to 51.1 percent. 

It might be tempting to interpret the last few years' coverage erosion as cyclical. But it occurred during a period of relative economic prosperity. As Bernstein and Shierholz point out, this suggests a structural change in employer-sponsored coverage that is almost certainly related to unrelenting health care cost growth. In other words, even though employers as a group were doing relatively well financially, the explosion in health cost - about five times general inflation and four times workers earnings from 2000-2006 - encouraged employers to move away from coverage.

Second, the erosion of coverage hasn't just occurred to those at the edges of the workforce, but across the board, eating into high paying, stable employees as much as low-income workers whom we might expect to be marginalized. The report provides extensive tables that break out the findings by industry sector, educational level, corporate role/position. The results are consistent. Here's the authors' comment:

The burden of these employer cuts is not carried by part-time or marginal workers. Rather, the most dramatic loss is among workers with the strongest connection to the labor force.

To me, these points have bigger messages.

Employers Cover Only Half Of Workers
Let's take the smaller one first. These numbers - remember they're from reputable surveys conducted for years by the Feds - say that only half (or less) of all US workers have health coverage. This is not a new or unique finding. Here's a quote from a Bureau of Labor Statistics report, Employee Benefits in Private Industry 2007, issued last August 22:

Seventy-one percent of workers had access to medical care benefits, and 52 percent participated in a medical care plan.

(I should acknowledge that these two sources are at odds with the Kaiser Family Foundation/Health Research and Educational Trust (KFF/HRET) data - see Figure 3.6 in their Employer Health Benefits 2007 Annual Survey report - which estimates that 65% of American workers currently have coverage from their employers.)

I have always found it difficult to reconcile the fact that, while a large portion of American workers apparently don't receive health coverage through their employer, we "only" have 50 million uninsureds. In the 20 years I've worked on or around this issue, this has made no sense to me, and I've never been able to get anyone to explain the discrepancy satisfactorily. So while I nod at the official uninsurance numbers, I suspect they're actually much bigger.

Over the last several decades, we have come to understand a great deal about the relationship between health and productivity. If the employer-based system is now only capable of delivering coverage to half its workers, then that has immense implications for our national ability to be productive and competitive in the global marketplace.

Focus On Fixing The System, Not The Problems Of The Uninsured
More importantly, while, yes, our uninsurance problem looms large, in the end, it pales in comparison with this fact: Mainstream Americans, who historically have had coverage over the last 40 years, are now losing it. So it is a mistake to frame health care reform against the context of the uninsured, at least as we have traditionally understood that population. That approach suggests that health care's problems are isolated to a currently disenfranchised minority rather than directly affecting all of us. Worse, it distracts us from the more pernicious problem, which is the severe operational dysfunction that pervades the whole of the American health care enterprise, one-seventh of the current US economy, one-eleventh of its jobs, as well as quality-of-life and financial impacts for virtually all the American people.

One deficit in the study is a description of the uninsurance problem. While many workers and families have lost coverage, those who still possess it have much skinnier benefits and higher out-of-pocket requirements than in the past. (Which means that when health coverage premium inflation is understood in the context of cost per unit of benefit, the actual cost growth rate is MUCH higher than the 5 times general inflation number I cited earlier.) A recent Watson Wyatt study showed that nearly half (47%) of all employers now offer a High Deductible Health Plan (HDHP), with or without Health Savings Accounts (HSAs). Now consider a recent EBRI/Commonwealth study that found a lower penetration of HDHPs in the market, but also learned that employers were 5.5 times as likely to provide HDHPs WITHOUT HSAs as they were to provide a HDHP and fund an HSA. In other words, most of us are paying a lot more for much less coverage than in the past, and that gradual degrading of benefits makes it increasingly difficult to come financially intact out of any significant health event.

So if the news is that rank and file Americans now face losing health coverage or going personally bankrupt if they get sick or are hurt, then our focus now should NOT be on the uninsured, but on reconstituting the adequacy and availability of coverage. It should emphasize the balance between what care should cost in a rational marketplace, and what most of us are able to pay on our own or through some collective mechanism. In the process of making coverage whole and available again, any moral society that is also devoted to its own self-interest would re-enfranchise those who had been disenfranchised by the failings of the previous system.

Despite the most fervent hopes of the American people, it is extremely unlikely that, when a new Administration takes office next year, health care policy reforms can be brought to fruition that make care in this country more affordable and accessible. Achieving that would require overwhelming the special interests who, as a new study from the Center for Responsive Politics again makes clear, now bring the cash to bear - $445 million in 2007 - to dominate Congressional health policy, and to continue the spectacular unwarranted variation and waste - half of all health care dollars - that lies at the heart of the crisis.

Even so, as progress in the market continues to accelerate, many of health care's cost issues could begin to subside and resolve. We're seeing tremendous movement toward transparency, decision-support and accountability throughout the continuum in the rapidly evolving Health 2.0 market. Access to better and ever-cheaper tools is facilitating information exchange and ultimately, more effective population and personalized health management. New attention to the medical home is revitalizing primary care and promises to curtail unnecessary downstream services.

The market can make care and coverage less expensive and more available. But getting to a system that assures appropriate care to everyone within our borders must be facilitated through policy. It will require political will, backed by a national understanding already firmly in place within our largest corporations, that without secure access to health care, our people cannot be highly productive or continue to lead on the global stage.

I doubt this important new, cautionary study about the character of America's employer-sponsored coverage system will get much visibility or traction within health care reform circles. But it should. Building the will to address what's actually wrong with the system - rather than developing a patch-quilt of half-measures built on ideology - demands looking at and thinking hard about the realities of how our health system functions.

Employer-sponsored coverage has many positive attributes. While it may have emerged out of less-than-perfect circumstances, over time it has come to correctly link the value of health with productivity and competitiveness, giving the employer a clear (though not the only) stake in ensuring that workers and their families are secure.

That system is increasingly in shambles. It can be fixed or replaced. But we must do one or the other. The status quo isn't working or good for Americans, our employers, or the future of the nation.

Deep thanks to Synthia "Hawkeye" Molina of health care technology intelligence firm Central IQ, for sending the Bernstein/Shierholz article my way.

Brian Klepper is an analyst, commentator and Principal of Healthcare Performance, Inc, a health care business development practice based in beautiful, balmy Atlantic Beach, FL.

By Dov Michaeli MD, Ph.D

I am not a health care policy wonk, or a wonk of anything, to tell the truth. But having observed the heated arguments, the indecipherable terms and acronyms, and the general sense of helplessness in breaking the political logjam, I asked a naїve question: how do others deal with the issue?

 I looked at the British system, which I know quite well. I also looked at the Japanese system, which I knew from my visits to the country and contacts with Japanese doctors, professors, drug companies, and just plain folks. Finally, I looked at the Taiwanese system, which I think is an unsung hero that deserves more recognition.

The British system

The Brits are very much like us economically, politically and culturally. They have a much more cynical attitude toward government than we do, if you can imagine that.

So here are, in general outline, the salient facts about their system.

· The “macro economic” aspect: the percentage of gross domestic product (GDP) spent on health care: 8.3

· Average family premium: None; funded by taxation.

· Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.

· The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.

· How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.

· What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.

Finally, The brits love to gripe about everything: traffic, the schools, the weather, and yes--the NHS. But try to suggest  that health care should be privatized and you will be met with hostility, as I witnessed personally, and as the Conservatives found out to their dismay in the following election.

The Japanese system

· Percentage of GDP spent on health care: 8

· Average family premium: $280 per month, with employers paying more than half.

· Co-payments: 30 percent of the cost of a procedure, but the total amount paid in a month is capped according to income.

· Japan uses a "social insurance" system in which all citizens are required to have health insurance, either through their work or purchased from a nonprofit, community-based plan. Are you listening Barack? Those who can't afford the premiums receive public assistance. Most health insurance is private; doctors and almost all hospitals are in the private sector. Take that, free market zealots.

· Japan boasts some of the best health statistics in the world, no doubt due in part to the Japanese diet and lifestyle. But also due to superbly trained physicians and surgeons. And due to almost fanatical emphasis on preventive medicine. To wit: Japan has  the highest rates of stomach cancer in the world. But almost every Japanese undrgoes an annual gastroscopic examination. Consequently, most stomach cancers are detected at stages 0 and 1 (in other words, very early). This results in a low, and decreasing mortality rate. On the other hand, in the U.S gastric cancer is detected mostly in stage 4, sometimes in stage 3--either way too late for curative surgery. Mortality rate--close to 100%.

Unlike the U.K., there are no gatekeepers; the Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. I have been privy to some aspects of these negotiations. The government gets into the minutest detail of the charges for procedures and drugs. Because Japanese culture abhors confrontation and fosters consensus, these negotiations are long, arduous, but at the end of the day everybody signs on. This helps keep the cost down.

· What are the concerns? In fact, Japan has been so successful at keeping costs down that Japan now spends too little on health care; half of the hospitals in Japan are operating in the red. Having no gatekeepers means there's no check on how often the Japanese use health care, and patients may lack a medical home. These are of course policy concerns. But I had the occasion to ask several colleagues and some regular people I met, what their concerns were.  Almost universally the answer was: none. Not a scientific poll, but telling nontheless.

The Taiwanese system

· Percentage GDP spent on health care: 6.3! This should be music to the ears of liberals and conservatives, Democrats and Republicans alike.

· Average family premium: $650 per year for a family for four.

· Co-payments: 20 percent of the cost of drugs, up to $6.50; up to $7 for outpatient care; $1.80 for dental and traditional Chinese medicine. There are exemptions for major diseases, childbirth, preventive services, and for the poor, veterans, and children.

· Taiwan adopted a "National Health Insurance" model in 1995 after studying other countries' systems. Like Japan and Germany, all citizens must have insurance, but there is only one, government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada's -- and the U.S. Medicare program.

· Taiwan's new health system extended insurance to the 40 percent of the population that lacked it (sounds familiar?) while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen has a smart card, which is used to store his or her medical history and bill the national insurer. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country's single insurer, Taiwan's health care system has the lowest administrative costs in the world.

· What are the concerns? Like Japan, Taiwan's system is not taking in enough money to cover the medical care it provides. The problem is compounded by politics, because it is up to Taiwan's parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.

Some naїve questions

· Why don’t we hear more about the Japanese and Taiwanese systems in the media, in the political debates, in congress, in health care forums debating ad nauseam how to fix the system?

· Are we so hopelessly captive to commercial and political forces that have a stake in the status quo, that nothing can be done to change it?

· Why can’t we do it? Are the Taiwanese so different from us? Are they smarter? Are we so dumb?

So please, all you policy mavens: please enlighten this naїve layman; why do we need to reinvent the wheel? It has already been invented in Japan and Taiwan. And it works!

Lynn Jennings

On blogs like this, people like me write analytically about issues which are often, at best, conceptual to us.

Not so to the guys in the rough and tumble world of health care finance. I remember that the first time I went to dinner with Lynn Jennings, I only knew that he was CEO of Alliance Underwriters, working in reinsurance, and that he is a former President and a current Board member of the Self-Insurance Institute of America (SIIA). SIIA is the national association of third party administration firms, the organizations that administer health plans for self-funded employer health plans. As we were walking into the restaurant, he turned to me and said, "In reinsurance you make a very sizable bet and find out three years later how things turned out."

Over time, though, as I've come to know Lynn better, I've found he has a profoundly practical view of the world, supported by a belief that careful management makes it possible for health care to work far better than it usually does.

Here is his advice to employers on managing employer-sponsored health plans. Whatever your philosophical orientation, these are sound recommendations for employers who must grapple with the difficult choices associated with employee health benefits.

Brian Klepper

For 40 years, I have worked in the complicated world of self-insured group health plans. I have led a third party administrator (TPA), underwritten stop-loss coverage and, with my wife Judy, overseen a utilization management firm. Now I’m also building employer-based clinics.

Over time I’ve been struck that most interests in the health care equation want care to cost more, not less, and that it is difficult for the responsible employer to navigate through this system. Some employers don’t believe that they can control costs, and have simply lost faith in their power to impact how the care delivery and administrative processes work.

I strongly believe otherwise. Here are some principles that I think can help any employer gain control of health plan quality and costs.

1. Make your plan affordable!
Design your benefit plan – including the required contributions and the deductibles – to work for your least compensated employees. If your company has a wide compensation range, consider a tiered plan that ties contributions and benefits to one’s ability to pay. 

Cover ancillary benefits only if the basic package remains affordable.  Adding dental coverage isn’t helpful if it results in contributions that are unaffordable to your rank and file employees.

2. Dollars paid through benefits are dollars unavailable for salary!
Strive for balance in your health plan. While “frequent flyers” may appreciate a “top drawer” benefit structure, most employees will see no benefit. Money saved can be applied to better pay.

3. Don’t insure what you can self-insure!
The cost of self-insuring predictable risks is nearly always less than insuring that risk. Budget internally for known losses and insure the unpredictable and unaffordable. This is true in auto, homeowners and health care insurance.

4. If your vendors’ interests aren’t aligned with yours, don’t expect them to reduce your health care costs!
Understand the motivations of your health plan partners and suppliers. How will your insurance company (health plan administrator), hospital and doctor be affected if your costs dropped 25 percent? If your broker is paid by the insurance company, what will his/her reaction be? 

A rate increase to you is a raise for everyone else.  Only the employer, your employees and the consultants you pay directly have a vested interest in lower health care costs.

5. Pay your brokers & consultants directly!
Your advisors work for whoever pays them, so if you don’t pay them directly, they don’t work for you!

Insist that you – and only you – pay them. Only then can you be assured of how much they are receiving and whom they are loyal to. Ask all health plan related vendors – e.g., your administrator, insurance company, health management company, network, pharmacy benefit manager – for compensation disclosures.

6. Let vendors know that you expect and will measure results!
Set meaningful, attainable and measurable goals for your plan, like a specific reduction in ER visits, inpatient admissions per 1,000 members, or participation in health risk appraisals. Then communicate them to vendors so they understand what you expect and are motivated to find solutions that will help achieve them.

7. Control your data, externally!
Health care is expensive. If you self-fund your health plan, the risk and cost are yours, and the claims data that result are yours too!

Many independent data warehouses can collect the data from your administrator monthly or even daily, and then store it in a standard format. Your administrator should willingly and, at no additional cost to you, transmit your data to your warehouse. Make sure the transmissions include all relevant data: enrollment, medical, PBM, dental and vision claims.  By having ready access to your own data, you can always know your actual numbers. The ability to measure is the ability to manage.

8. Audit your vendors!
You spend significant dollars on health care. At least every two years, engage an independent auditor to review your health plan’s performance. If your administrator will not agree, change.

9. Don’t be held hostage by vendors!
Doctors and hospitals whose fees are excessive, or who insist on referring outside your network, do not need to be included in your plan.

Take charge. Refuse to include providers who would hold your plan hostage. Let providers know that abusive practices won’t be tolerated.

10. Be wary of a health plan’s “packaged” services!
Health plans are typically built on an array of specific functions: administrators, stop-loss carriers, provider network, utilization management programs. Sometimes plans require that you use arrangements that bundle one service with another. Seek best-in-class products and services whenever possible. Every service and product should stand on it’s own.

11. You’ll get what you accept!
You have the right and obligation to insist on excellence.

Penalize vendors – e.g., health plan administrators consistently unable to pay claims accurately the first time, or disease management programs that cannot prove savings and other programs – if they don’t perform as promised.

12. You can’t please everyone all the time!
No matter what you offer, some employees still won’t like it.  Get over it.  Do what is right and what you can afford.  Most will appreciate it.

13. Innovate! Experiment!
Try new things.  The definition of insanity is doing the same thing, over and over again and expecting a different result. Not everything works for everyone and the “tried and true” may be obsolete!

by Margaret Cary, MD, MBA, MPH

Step right up, folks, for the chance to win your life. Oregon will randomly choose 3,000 lucky, low income winners from among the more than 90,000 (out of at least 600,000 uninsured) who applied for available vacancies in the Oregon Health Plan lottery—one in thirty. A decade ago this same plan was considered progressive—a health plan for folks who earned too much to qualify for Medicaid and not enough to afford medical insurance. These lucky winners will be the first since the Oregon Health Plan’s budget was capped in mid-2004. With limited resources for a huge demand, how would you choose? Would you select the 50 year old woman with a rare disease who cannot afford the monthly cost of $500 that would increase her life? Would you choose a 72 year old man who needs a pacemaker? On the same day the Los Angeles Times featured the Oregon lottery, on the other side of the country the New York Times contained an essay, “Many Doctors, Many Tests, No Rhyme or Reason,” by Dr. Sandeep Jauhar. Dr. Jauhar’s book, Intern: a Doctor’s Initiation , was reviewed last Sunday by the Times . He wrote of a cardiologist friend who must do at least ten nuclear stress tests each month just to pay for the overhead for the machine’s various costs. This physician tried to do the right thing when he started practice, but his patients—the worried well—wanted technology. If he did not order the tests, the patient would see the next cardiologist, who would order them, and then be praised for his thoroughness. CT scans for headaches and stress tests for young, healthy people with palpitations. This technology is much more expensive and labor intensive than a blood test to determine whether someone is tired from anemia or from hypothyroidism. These are people trying to survive, by taking a chance on winning the lottery or by making a living by increasing volume. Someone wins. Someone loses. Last week I attended an event, “Our Looming Medical Cost Catastrophe: What’s to Be Done?” I thought I was in the 1990s—the same points and the same arguments. The main difference is the numbers—costs, people, procedures—have increased. Significantly. Déjà vu, anyone?

by Pat Salber

How many times have you heard health professionals, politicians, and others say: “Here in the US, we are fortunate to have the best health care in the world.” I still occasionally hear someone say this, but certainly not as often as in the past. The proponents of this myth generally follow the “best care” statement by noting that Canadians come to the US to get procedures they have to queue for in their own country. These same people scoff at “socialized medicine” in the UK believing that we are must be getting better care than those poor Brits subjected to “government medicine.”

Well, gang, it just isn’t so. The November issue of Health Affairs reports on the results of a 2007 survey of adults in seven countries, including the US, that asked about their health care experiences. The survey and resulting paper, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” are the work of researchers at the Commonwealth Fund.

Here is a summary of some of their findings:

• 42% of people in the Netherlands feel that their health care system works well and that only minor changes are needed. In contrast, only 16% of Americans feel that way about our “system” and 34% feel it needs to be completely rebuilt.

• 35% of Americans are “very confident” that they get high-quality, safe care. This is similar to Australians perception of their system and better than the 28% of Canadians and Germans who feel that way. In the Netherlands, 59% are very confident and only 5% are not confident (compared to 21% in the US) about the quality and safety of their care.

• More people in the US and Germany had short waits for elective surgery compared to the other countries, but more people in the US reported not visiting a doctor when sick, skipping tests, treatment, or follow up, and not filling prescriptions or skipping doses of medications because of cost than people in any of the other countries.

• Only Canada (22%) was below the US (30%) in the percent of patients who reported being able to be seen on the same day they called.

• 36% of adults in the US had visited an emergency department in the past 2 years. About 40% of those said the visit was for a condition that could have been treated by a primary care physician is one had been readily available. The figures were similar for Canada, but far lower in Germany and the Netherlands.

Hmmm. According to this report, it appears that you can get stuff you don’t need very badly (e.g., elective surgery) pretty quickly in the US, but more than a few of us are shut out altogether when it comes to getting needed care for acute and/or chronic illness.

When it comes to health care costs, it is remarkable that US per capita spending is about double of the next most expensive care (Canada). These figures are worth looking at in black and white:

Not only are we the most expensive health care in the world, we don’t even cover everyone. 16% of Americans are uninsured at any given point of time (25% are uninsured at some time). Compare that 0% to <2% in the other 6 countries.

So we pay more, some of us get much less and others get nothing compared to the other countries in this study. Best health care in the world? Unless you are rich enough to buy whatever you want, whenever you want it, you might be better off in the Netherlands!

Brian Klepper 

Now that health care reform is once again an active, visible issue in state governments and the presidential campaigns, the ideas are flying fast and furious. Predictably, some ideas are better than others.

Over at Health Care Policy and Marketplace Review, Bob Laszewski asks an important, practical but vexing question for universal coverage advocates: Can you really mandate people to buy health insurance?

Mandated health insurance is a plank in the Clinton campaign's health care reform plan and is a key way that Ms. Clinton and Mr. Obama differ on that issue. (I don't know why Presidential candidates should provide this level of operational specificity at this point in the game - there are lots of different ways to skin the universal coverage cat - but they have.) Under Ms. Clinton's plan, all citizens would be required to prove that health coverage has been provided to them or that they have purchased it.

To illustrate the difficulties in actually using a mandate, Bob points us to the penalties being developed by the Massachusetts Department of Revenue for citizens who fail to buy health insurance. The 2008 proposal would tie the penalty to the lowest coverage cost offered through that state's health care program, and would be $912/year for a person older than 26 years. As he points out, the burden would fall most heavily on the group that makes just too much money to receive subsidies.

I recently described nearly the same problem in California's health care reform proposal, where a couple with a household income of $54,000 would have to fork over $12,000 for coverage. It's difficult to see how this can work.

There are two issues here. First, most of these state efforts assume that whatever universal health coverage is achieved must be comprehensive, an extremely expensive proposition. (Yesterday's news that US health care in 2006 had crossed three different annual financial thresholds - $2 trillion, 16% of Gross Domestic Product and $7,000 per person - ought to be sufficient evidence of that.)

But as a practical matter in getting a program underway, it may make far more sense to shoot for universal coverage of basic care services. Of course, defining "basic" is the trick here, for several reasons. (This is a terrifically complicated problem. Does basic include three liver transplants? Is it the same for healthy person and one with spina bifida, or does it change with health status? How can we define it?) While social justice is an undeniably compelling reason to implement universal coverage, there's a lot more to the universal coverage issue than simply that. Without universal coverage for at least basic health services that associate dollars for every patient who presents, the nation's safety net hospitals will gradually be overwhelmed by the demand for uncompensated care. (Today's NY Times article on Atlanta's Grady Hospital's financial dilemma does a pretty good job describing the reality of this problem throughout the country. A few weeks ago, I also wrote about Grady's problems and how they're at the edge of the much larger looming health care crisis.)  A "basic" program would be far less expensive and easier to finance than a comprehensive program. And it should be possible to create a basic program for all Americans, and then let insurance companies build market-based supplemental programs on top of them.

Second, a mandate effectively caters to the insurance industry, suggesting that the only way that universal coverage can be achieved is for people to buy coverage (and let the insurance companies take a profit). But universal coverage could be built in other ways as well. For example, there is no reason why we couldn't establish next generation community care clinics around the country, and designate a range of primary care providers who would "take assignment" for any care delivered through the program. Anyone in America could show up at a clinic or a designated provider and receive the basic care they need without paying much or anything. The care would be detailed in the EHR and a bill submitted to the Feds or their intermediary.

A mandate would also create extremely complex and expensive administrative issues. If we required everyone to buy coverage - including all those who aren't subsidized but who would have trouble affording it - then we'd have to establish a monitoring/tracking function that could make sure that everyone did what they were supposed to do, and then punish the offenders.

But the deeper problem with the state and national reform efforts currently on the table is that they finance reform upfront by requiring a lot more money from the people paying the bills, while talking in vague platitudes about cost containment. All the real concessions come from the purchasers, and virtually none come from a health care sector where we KNOW that care and cost are extraordinarily variable between providers, and that between a third and half of all care and cost are unnecessary or inappropriate.

After 25 years of managing the care process, its not like there's any mystery about what health care actions save money and get better outcomes.

We know, for example, that paying doctors salaries and not letting them make money on the procedures they prescribe, drives down cost significantly.

We know that, in any market, if you compare the resource consumption of all doctors within a given specialty for a particular condition, and hold the outcomes constant, that there will be a 6x-8x difference between the least and most expensive practitioners. You can save a lot of money if you look for the physicians who consistently get the best outcomes at the lowest costs, and steer your patients to them. And if you make your findings known publicly, it creates a competitive market for the doctors, and the quality and cost of the care will likely improve across the market.

We know that, for routine conditions, doctors who have modern tools and follow evidence-based best practice guidelines generally have lower costs and better outcomes.

We know that generic drugs perform just as well, in most cases, as brand drugs, and are a lot cheaper.

We know that, to the degree you can open up access with zero or very low co-pays, particularly for low-income populations, that you'll nip exacerbated care in the bud.

We know that, if you can identify patients with chronic diseases, and then intervene with face-to-face lifestyle, education and behavioral counseling, you have the best chance of lowering that population's costs, which typically account for half or more of any credible population.

We know that, if you can tie payment to outcomes, you'll change reimbursement incentives from rewarding more care to rewarding only the right care, and the total use of services and cost will be reduced.

We know that team-based medicine, where doctors collaborate, is more effective and efficient than siloed medicine.

We know that if we can obtain pricing/performance transparency information, we can identify the top vendors, and then we can use that information to make better purchasing decisions. We also know that, at this point, the information that's become available is mostly too complicated and arcane for most consumers to use. But in the future analytical results will flow into decision support tools that will make objective purchasing decisions much easier.

We know that, until the pricing and performance of ALL health care players, services and products - doctors, hospitals, health plans, suppliers, particular treatments, drugs, devices - are made transparent, it will be impossible to really get costs under control. For example, I'm a big proponent of carefully constructed Pay-for-Performance programs, but until health plan performance is just as transparent as the plans have demanded that providers be, the gains would simply accrue to the plans. In other words, change the incentives and you'll likely change the way care is delivered. But if the health plans aren't transparent, how will we know how much waste and money was actually eliminated, and what happened to it. Was it shared with the providers who produced the efficiencies? Was it returned to purchasers in the form of reduced premiums? Or did it simply bolster the earnings of the health plans.

The real issues of health care reform have to do with universal coverage and cost. Universal coverage can only be achieved through policy change, because at a societal level, there must be a governmental assurance of payment for the services.

But its unlikely that real cost-containment can take place through policy reforms, because the most powerful lobby, the health care industry, has the advantage of a Congressional system that is highly susceptible to influence. Facing the possibility that their revenues could drop dramatically, the industry would use all its sway to prevent meaningful reforms. Even so, there are tremendous changes afoot in the marketplace - Health 2.0 is the best example - that will over the next few years infuse unprecedented levels of transparency and decision support into health care, and begin to rationalize the waste that has had a grip on the throat of purchasers and patients for decades.

Unless we can convince America's non-health care business community to come together and roll over the health industry's lobby, in terms of the policy-based reforms, we should resign ourselves to these realities and shoot more modestly, for universal coverage of basic care. That would be a critical foothold to build on, and would pave the way for much more progress.

We need to abandon lofty and impractical approaches that are constructed by dreamers, and develop practical solutions that are based on actions we already know work. Any other approach will almost certainly produce coverage at an unsustainable cost, and simply postpone and intensify the crisis.

About a year ago, the Executive Director of a very prominent business association called and asked me to define the list of reforms that any reform proposal must include if it hopes to be effective. That list is up on my site under the Reform section. Before it was posted it was reviewed and found acceptable by about 30 colleagues. Please feel free to take a look and offer comments.

Brian Klepper

In an extraordinary move earlier this week, the politically-appointed Fulton-DeKalb Hospital Authority, the governing body over Atlanta's Grady Health System, unanimously and voluntary stepped aside, to be replaced by a new non-profit corporation. Projecting a $55 million deficit this year, the hospital had just three weeks of cash on hand. It needs $300 million immediately for sorely needed renovations, and must deal with $63 million in accumulated debt to its biggest creditors, Emory University Medical School and Morehouse School of Medicine. New oversight was the predicate for a hoped-for financial bailout from business, philanthropies and financial institutions.

Other Atlanta hospitals are undoubtedly concerned that Grady will fail, and will probably do everything possible to support a bailout. The last thing they want is for Grady's patients to come to their facilities. Now would be a good time to rally business leaders and legislators, who nearly always go to fancier hospitals, which of course has been a big part of the problem.

Grady’s turmoil should be recognized as the first small shock of much larger seismic event, long in the making, a concrete sign of America's relentlessly intensifying health care crisis. The wrath falls on our most vulnerable - those with health problems or with few financial resources - as well as on the institutions and professionals that care for them.

Nearly every large and mid-sized city has a Grady that struggles with similar issues. In addition to being the health care resource to the poor, they are often academic centers - clinicians-in-training need SOMEBODY to learn on. They can be home to a region's highest expertise, particularly related to crisis care. Many house their community’s neonatal intensive care unit and burn unit, as well as the level 1 trauma center, which brings with it disaster preparedness responsibilities. These are precious services that we somehow EXPECT will be there when we need them. So if a safety net hospital closes, the loss to the community and the replacement resources required are immense.

Grady, like other safety nets around the country, isn't failing due to mismanagement, although some of that almost certainly plays a role. Instead, it is the slowly-boiled frog, its financial base eroded over decades as it increasingly became the hospital of the inner city, the center for care for Atlanta's low-income and uninsured residents. As governmental support steadily dwindled, demand for its services rose. Fully 75 percent of Grady's patients are on Medicaid, which pays less than the cost of care. Only 7 percent have commercial insurance.

Safety net hospitals are famous for struggling through, but presumably there's a calculus here. As small businesses are increasingly priced out of the coverage market, and as state government, facing budget crisis, cut back on publicly funded coverage, the burden on the safety nets will continue to rise and the resources will continue to decline. At some point the demand-resource mismatch will give way, and some will topple. Their patients will seek care at other hospitals, which will simply transfer the burden elsewhere.

We can keep the safety nets afloat. The most logical solution would establish universal coverage for "basic" care services - we have to define what "basic" means - which would associate dollars with each presenting patient. We could also update the EMTALA laws that govern how emergency patients are seen, so those seeking minor care can be managed in less expensive settings.

But these answers don't seem likely at the moment. Despite current rhetoric, universal coverage legislation is doubtful unless we can find ways to significantly drive down cost. Legislation that drives out unnecessary health care spending would reduce health industry revenues, though, an unlikely prospect so long as lobbyists drive Congressional policy.

Still, we should think deeply about what Grady's troubles really mean, and consider this case not in isolation, but as possibly representative of systemic forces. Without significant system change, we could see more safety nets falter in the next few years. Each community where a failure occurs will gradually appreciate the importance of its loss. As the poor turn to the remaining hospitals for care, the cascading impacts on the larger system could severely test America's commitment to care that is independent of an ability to pay.

And that would challenge our core values as a nation.

Brian Klepper

This week TDWI is delighted to take our turn hosting Health Care Wonk Review, a collection that highlights some of health policy's best observers. The quality of these 14 posts is very high, and well worth your time.

As HWR has gained visibility and popularity, the number of submissions has risen. We couldn't publish them all, so chose the ones we thought were must-reads across industry sectors. (Apologies to those we didn't include this time.)

Before we begin, a quick announcement. Envision Solutions, LLC and Trusted.MD Network have launched the second annual global survey of healthcare bloggers.  The companies are producing this poll to shed additional light on why people blog about health-related subjects.  Click on the link to learn about and take the survey.  The study will close on October 15.

Now onto the show!

Physician Temper Tantrums. Over at Managed Care Matters, Joe Paduda picks a scab and elicits a (deliciously) minor furor. He argues that when payors use the results of claims data analysis to encourage patients to see better performing doctors, they are well within their rights as purchasers. He also notes (and I agree) that when doctors reject out-of-hand claims data as inherently flawed and inappropriate to provide quality analysis, they may not appreciate the progress in the available tools and methods, and may be simply defensive. Actually, he says "their actions look more childish than professional from here." A provocative piece.

No Docs in This Box. Retail medical clinics are popping up all over as an inexpensive alternative to a full-blown practice or the ER. Traditional providers are crying foul, but InsureBlog's Bob Vineyard suggests this is the pot calling the kettle black.

Abusing The Orphan Drug Law To Rip Off Customers. In a damning indictment of a drug company's business practices, David Williams at the Health Business Blog discusses Questcor Pharmaceuticals announcement about “a new strategy and business model for H.P. Acthar Gel(R).”

What Are The Real Savings In Medical Tourism. MedTripInfo's Michael Horowitz analyzes the probable total savings for a hip replacement obtained overseas. They're substantial.

Medical Justice League of America. The Sentinel Effect's Richard Eskow describes a new group that provides "gag order" forms to dissuade patients from reviewing their docs online, and also promises to "relentlessly" fight med mal lawsuits." The situation he relates would be hilarious if it weren't so lopsided and scary.

Make Sure Your Online SaaS Vendors Are Appliance Capable. The Healthcare IT Guy, Shahid Shah, provides sage advice on why you should not depend on "software in a cloud" without a backup plan. With big outages from Microsoft, Skype, eBay, and PayPal recently making headlines, it is wise to make sure you're protected. A fascinating and smart look at the pitfalls and realities of letting other companies be responsible for your mission-critical IT functions.

What The Lumenati Are Saying May Surprise You.  The ever-entertaining Matthew Holt is making the final dash toward hosting the Health 2.0 conference, where the discussion will focus on a significant portion of market-based reform, and the players will be none of the usual suspects. Meanwhile, back at The Health Care Blog, he ticks off some surprisingly lucid health care insights from the most unexpected sources.

Mitt Romney's Health Plan - A Foot In Each Canoe.  Over at Health Care Policy and Marketplace Review, Bob Laszewski wryly observes that conservative Presidential candidate Mitt Romney would like to have it both ways. He gloats over the Massachusetts reform he helped to engineer while assuring his political base that it wouldn't work elsewhere. (It's also not yet clear that it is going to work in Massachusetts.) It's a delightful bit of political dissonance, seen through the clarity of Bob's highly polished health policy lens.

BiPolar Diagnosis in Children: Another Epidemic? Here at The Doctor Weighs In, the erudite Dov Michaeli recounts a recent review article from the Archives of General Psychiatry. Between 1994-1995 and 2002-2003, an 8 year period, the rate of bi-polar diagnoses in children increased 40 fold! He lists a range of possible explanations for the epidemic, but settles, gloomily and cynically, on money. By explicating an immense but relatively obscure problem, he lays bare a pervasive trend that's corroding our health system. A must read!

Conflicted View on the Pitfalls of Government-Sponsored Comparative Effectiveness Research. In a withering analysis, Roy Poses at Healthcare Renewal rebuts a recent commentary by WSJ Editorial darling Scott Gottlieb. Dr. Gottlieb disparaged government-sponsored research as biased against costly drugs, while ignoring similar and more odious flaws in private sector research practices. AND Dr. Gottlieb conveniently neglects to disclose that he's associated with the biotechnology sector. Superb.

To Hell and Beyond: Dave Holland's Terrible Story. At Workers' Comp Insider, Julie Ferguson points to a particularly gruesome work-related accident by way of reminding us that these incidents are still all too common. Julie's perspective is particularly poignant, because it is also a reminder that what lies beneath the day-to-day work  of the people who write for and read this review is the vital goal of preventing and managing the suffering that is too often a part of life.

Katrina: Two Years Later Are Health Systems Better Prepared?  On the second anniversary of Hurricane Katrina, NewsHour correspondent Tom Bearden asks a coastal area provider if the health systems are now better prepared. The short answer is "No," according to the  interview excerpted by Jane Hiebert-White on Health Affairs Blog.

Cookbook Medicine Saves Lives.   A pretty good cook (I can vouch for her!) as well as a physician, The Doctor Weighs In's Pat Salber relates the substance of a July 23 article in the Archives of Internal Medicine. She describes a new heart failure guideline that improves outcomes when followed by clinicians, and details the range and depths of those improvements. She concludes with a quote from  the lead author, telling us that if these protocols were followed in hospitals across the country, they would result in 40,000 fewer deaths and 1.4 million fewer hospital days annually. Keeping in mind that this is just one condition in the vast complex of health care, it is a deeply compelling point.

Reform's Tougher Problem. I've been a bedouin lately, wandering from oasis to oasis, grateful for the chance to publish on Pat Salber's The Doctor Weighs In, Bob Laszewski's Health Care Policy and Marketplace Review, and on Matthew Holt's Health Care Blog. This post, placed on Matt's site, summarizes what I've learned working for several years on the reform problem. I now believe that meaningful change can only occur through the leadership of the non-health care business community, the one group with more power and influence than the financially conflicted health care sector. Non-health care's business leaders will pursue this effort, not because they care about health care or social justice, but because health care's impending instability will threaten the stability of their own econonic environments.

Thanks again to Health Wonk Review for letting us host, and thank you for stopping by.

Brian Klepper

Over at The Health Care Blog, while my pal Matthew Holt is honeymooning with his lovely bride Amanda for the next week and a half, I've taken on a share of the guest cage-rattling responsibilities. Yesterday and today, I'm presenting the case against broker's excessive compensation and their financial conflicts with health plans. At the same time, though, I also point to their roles as sin-eater/intermediary in an increasingly contentious health plan - benefits manager/enrollee relationship.

So its not either/or. Stop in here first and then visit there.  There's plenty of rabble rousing to go around.

by Pat Salber, MD

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds.  We made small talk during the trip.  He told me he was hoping to leave Nevada soon and move to Oregon.  But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week.  The cab company deducts chunks of his pay  for their share of his revenues and to cover his health insurance premium and a tax on his tips.  His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health.  He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated.  He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run.  That means fast food, high fat, and lots of calories.  Also, how do you fit in exercise?  Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over? 

I found myself wondering what I would do if I were his doctor.  Of course, I would recommend he lose weight, alot of it.  And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day.  I would prescribe any needed medications.  And, I would tell him to join WeightWatchers, or better yet an on-line weight loss support program, like PEERtrainer (www.peertrainer.com).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule.  I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes.  He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better.  But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man?  I haven't come up with an answer.  Can you?

This is an oldie, but goodie, first published on TDWI September 15, 2006

Brian Klepper

I’ve filled a lot of airtime and column inches over the last couple years talking about the financial conflicts that characterize so much of health care. I’ve focused on topics like oncology drug rebates, Medicare D drug plan scams and unnecessary care by doctors and hospitals, but the truth is that these unethical and abusive practices abound in virtually every area of health care.

These outrages are often glossed over because they’re perpetrated by respectable people presumably working under the mantle of a higher mission. Of course many health care professionals are mortified by these practices and know that the system must change. I recently did a video commentary on financially conflicted care on Medscape and expected a physician backlash. What arrived instead was a large number of supportive letters from doctors chagrined by medicine’s diminished ethical values, and more letters from patients who said my comments validated their experiences.

Over at The Health Care Blog, Matthew Holt has spotlighted a nauseatingly shocking story about Mega Life and Health, a case that deserves as much visibility as we can give it. Mega is one of several insurance companies poised to exploit the erosion of group coverage through the relatively less-watched individual coverage market. It sends freshly recruited insurance sales people, often with little training in or understanding of insurance, door-to-door in middle and low-income neighborhoods. They sell policies that have high deductibles and severe restrictions on the amounts they will pay out.

Mega has a front organization, the (presumably not-for-profit) National Association for the Self-Employed (NASE), which is, of course, set up to sound like a trade association. The Mega sales people apparently tell prospects that they can get a better deal on their insurance by joining NASE – a strength-in-numbers argument – so the focus ends up being on NASE’s benefits rather than the details of the coverage. It’s a simple deception, but it seems to work.

One former Mega salesperson, Jay Norris, posted a comment about his experience on his blog. He and I spoke, and he gave me permission to reprint that comment here.

I started out in the health insurance business with MEGA. I watched how all the successful agents sold policies, and that was by not mentioning what all wasn’t covered. They just made it sound like a simple plan with a co-pay, deductible, and 80/20 coinsurance. That’s the only way somebody would spend so much money on a policy that doesn’t cover anything, if the agent lied to them.

Once I understood what I was selling, I had to quit and become an independent broker.

If the agent explained to these people what they were buying, there is no possible way they would have bought it.

An article that appeared in the Mobile Register in March 2007 quotes former Mega sales staff who echo the same sentiments.  And after Matthew posted his article a couple days ago, another former Mega sales staffer commented on his site:

I barely made it through Mega Life training about 5 months ago, but quit before going on my first appointment. They taught us to deceive clients during training by saying to focus on the NASE benefits and not the health insurance.

While selling Mega insurance may have caused a crisis of conscience for some of its sales staff, buying it appears to have been catastrophic for customers who had serious claims.

The July 21, 2007 edition of the Southwest Florida Herald Tribune reports a case of an electrician, Tom Main, who purchased a Mega family policy 18 months ago. Soon afterward, his son was diagnosed with cancer, and the policy paid only about $45,000 of $500,000 in bills before Mega dropped the Main’s coverage. (Mega Health's website now promotes their coverage as having a $1 million lifetime benefit per injury or illness, and a $5 million benefit for all injuries and illnesses.)

The family claims they thought they were buying a high deductible plan that would cover the majority of their bills, but the company responded that Mr. Main knew what he was buying. Donna Ledbetter, a company spokesperson emailed the reporter that Mr. Main

“understood the policy and at no point expressed that he had been told anything different about the policy by the agent who sold the policy, or express dissatisfaction with his coverage and benefit selections."

Spend 10 minutes on the Web and you discover that the Main family is not an isolated case. A 2005 Business Week story reports that the National Association of Insurance Commissioners (NAIC) provided information showing that Mega has been the subject of 14 state insurance regulatory investigations since 1995, and that its 2005 complaint rate was more than twice the national average, though down from more than four times the national average in 2003.

Now comes the interesting part, and here Matthew Holt deserves the credit for looking more deeply into the circumstances.

It is tempting to dismiss sleazy cases like this as the work of just another fly-by-night outfit taking advantage of the ignorant and unwary. But as Matthew points out, Mega is a subsidiary of HealthMarkets, which in turn is owned by three prominent investment banks: The Blackstone Group, Goldman Sachs and DLJ Merchant Banking Partners.

In fairness, Blackstone acquired Mega relatively recently, on September 15, 2005. Even so, if it was determined to clean up Mega’s business practices, that is not evident in the case described in the Southwest Florida Herald Tribune.

Nor is a change in Mega's tactics demonstrated in very recent customer complaints and former sales staff testimonials. In a March 28, 2007 interview, California insurance attorney Bob Scott said,

MEGA Life and their sister company, Midwest, continue to sell these products after settling a multi-million dollar class action settlement whereby they were ordered to advise [prospects] of the inner relationships between the holding company [HealthMarkets], these groups [NASE], and the insurance companies [Mega Life and Midwest], so that people would really understand that these groups are not really independent, that they don’t necessarily have the consumers’ best interests at heart, and that the insurance companies are pulling off a fraud on these insurance consumers.

And Mega's insurance products continue to be available in nearly all US states.

States Where Mega Products Are Licensed

In other words, some of America’s most respected and influential financial organizations are behind Mega’s shoddy business practices. They use deception to prey on our most vulnerable citizens, but are mostly hidden from view.

In part, America’s health care crisis has grown out of financial reward and the lack of transparency. Over decades, these industry characteristics have fostered an opportunistic culture that pervades the business practices of many professionals and organizations in this sector. Ultimately, it is reasonable to believe that reform will come from the outside, as influential non-health care organizations realize that the health care industry’s inability or refusal to self-regulate threatens their interests, just as Mega appears to threaten those of individual purchasers.

Finally, there’s this. Some of you may have been struck by the similarity between the case of the Main family and the family dealing with the rotten insurance company in the movie of John Grisham’s The Rainmaker. Remember Mary Kay Place, testifying, reading the gleeful insurance executive's letter that denied her claim one last time? It could just as easily been Mr. Gedwed, HealthMarket’s CEO, laughing at the rest of us, singing “You must be stupid, stupid, stupid.”

Brian Klepper PhD is a health care analyst and advisor. He can be reached at  904.343.2921, bklepper@gmail.com. Click