Chicago’s innovative plan to help deliver better medical care to its urban poor and decrease overall costs is proving more successful than critics originally anticipated. It sprung from the observation of University of Chicago Hospital’s executives that more than 40% of the over 55,000 patients who appear in its emergency room annually could be better and more efficiently served in a clinic or primary care physician’s office. The University of Chicago’s Urban Health Initiative was started in 2005 as a way to educate urban patients on when to use the emergency room and when to go to a clinic.

Innovative Chicago Hospitals Improve Care in Urban Areas

The program links each patient to a non-ER medical home where they can make appointments for non-emergency issues. The program was once led by Michelle Obama and has linked 5600 people to a medical home since it began. The idea behind finding patients a medical home is that redirecting non-emergency needs to a primary care physician or specialist at a clinic will result in higher-quality care for patients than they would receive at hospitals where costs are also much higher than at clinics. Decreasing the number of patients appearing unnecessarily for routine issues in emergency rooms will increase both cost-efficiency and quality of care.

Though these patients are not maintaining a consistent relationship with one doctor after they are referred by the University of Chicago to its directory of primary care providers, they are maintaining a closer relationship with a facility (their medical home) which helps target the national problem of those with chronic conditions not seeking preventive care. Increasing the rate at which these chronic conditions are addressed earlier and more consistently not only helps prevent premature deaths but also saves the healthcare system tens of billions of dollars. Though the problem of not seeking preventive care from a primary care doctor regularly is a national issue that transcends income groups, the problem is most severe in low-income neighborhoods such as those served by the Urban Health Initiative, where doctor’s appointments are low on the list of priorities.

The Urban Health Initiative has grown to include 24 community-based clinics and other providers and has a budget of over $6 million annually. The number of appointments made at clinics through program referrals have jumped nearly 40% to 3649 in the last year, compared to 2006. Critics point out however that in 2005 34% of patients (884 people) who were referred by the program kept their appointments at their medical home clinic. In 2010, that number has grown to 1386 patients – only 39% of all referrals.

Despite this criticism, the success of the program has been lauded nation-wide, to the point that the Urban Health Initiative is now poised to escalate research initiatives and teaching opportunities for physicians hopefully leading to its being a national model for medical care in urban areas.

The latest destination for medical tourism for American patients isn’t a tropical locale – in fact, it’s right here in the US. That’s right – some large employers are negotiating with hospitals in other states and paying for employees covered by the company health plan to seek treatment for major illnesses and surgeries outside their home counties. Hospital care accounts for over 1/3 of our $2.5 trillion annual health spending and this amount is projected to rise drastically according to government data – it rose nearly 6% last year alone. This increase is being driven both by increased use of hospital services and rising prices. In the face of this looming increase, large employers are trying to save money on their company health plans by negotiating a single rate with top-quality hospitals in other states which includes the fees for all medical services until the patient is discharged.

To encourage workers to use the program, companies waive deductibles, cover travel and hotel costs for patients and their families, and reduce co-insurance payments by as much as half. Even factoring in travel costs on the company tab and in some instances monetary incentives to workers, most large employers who’ve tried “domestic medical travel” say they can reduce their costs 20-40% by directing workers to facilities with higher-quality care and lower negotiated prices. Employers who’ve promoted domestic medical travel include Alpha Coal West, BridgeHealth Medical’s group of small and midsize companies, and the Health Services Coalition of employers and unions in Nevada. Alpha Coal West has reported its medical costs have remained flat even as such spending has risen nationwide in the nine years since it implemented the program.

Medical Tourism in the US

If domestic medical travel becomes popular amongst large employers, health industry experts argue the shift could improve quality of care overall and help drive down costs by “fostering a truly national competition.” Savings with domestic medical travel programs result not only from lower prices (negotiated between the company and the out-of-state hospital) but from fewer complications with procedures done at high-quality hospitals. Better hospitals perform procedures better, meaning fewer costs incurred after surgery to resolve complications. Any necessary follow-up care (like physical therapy) is usually performed at the local hospital and covered under the company’s normal insurance plan.

The concept of domestic medical travel is really nothing new; employers and insurers have always sent patients to very high-quality facilities for complex procedures like organ transplants. Domestic medical travel is taking this idea to another level, applying the same concept to more types of medical care like back, knee, and heart surgeries.

Some critics argue the movement toward domestic medical travel could backfire if employers and insurers forget about quality and focus only on cost-savings. Also, some workers (even with incentives and paid travel for patients and family members) are reluctant to travel for surgery. Though the programs are now voluntary, critics worry they may become mandatory and force patients to travel for their procedures even when they don’t want to. For these reasons, and because such programs can anger the local provider community, some insurers are reluctant to encourage domestic medical travel.

These considerations do not seem to be hindering the trend toward domestic medical travel, especially since major companies like Alpha Coal West have experienced such success (and savings) with their programs. It appears as rising medical costs continue to increase nationwide, domestic medical travel is the way of the future for major companies to flatten escalating costs while simultaneously providing their employees with the best quality of care.

Medical residencies are notorious for their excruciatingly long shifts.  Doctors fresh out of medical schools use their residencies to gain on the job experience in their desired specialty. Although residencies allow these young doctors to develop expertise, the long work hours can take a toll on their minds and bodies. Residents practice under the supervision of licensed doctors and continue their training as physicians.

In the past, a medical resident could expect to work more than 100 hours a week, with minimal rest in between. Things changed in 2003, when the Accreditation Council for Graduate Medical Education (also known as ACGME), cut down the hours to 80 weekly, although this ruling was not strictly enforced. Still, many shifts can last over a day, up to 30 hours with limited time to sleep.

A new proposal set by ACGME will cut down on mistakes and ensure that patients are safe.   Maximum shift lengths would be reduced hopefully reduce harmful medical from 24 hours to 16 hours for first year residents and to 24 hours for all other physicians. Additionally, attending physicians would be required to make patients aware that they are under the charge of a resident.  The new guidelines will require attending physicians to supervise residents more closely in an effort to improve patient safety. Still, these regulations would only affect first year residents. All other physicians would limited to 24-hour shifts.

Studies have shown that sleep-deprived residents are more prone to making medical mistakes.  A Mayo Clinic study revealed that fatigued, distressed medical residents were more likely to make preventable medical mistakes. Yet another study found that residents were three times as likely to say that they’d made an error during months when they worked one 24 hour long shift.  In 2004, a report discovered that medical residents who worked all night shifts were ultimately accountable for over half of medical errors.

Overworked Medical Residents May Be Catching a Break

Ultimately, some medical mistakes prove fatal. One famous medical malpractice case is that of Libby Zion, an 18 year old college student who died when her overworked, fatigued medical residents prescribed her medication that reacted dangerously with her antidepressants.

Grueling shifts can compromise the health of the doctors themselves. Dr. Shannon Gulliver recently wrote a piece for the New York Times in which she detailed her own weakened immune system, a result of the long hours and high stress of her position. She developed esophagitis, while her colleagues themselves developed shingles, fungal infections, C. difficile diarrhea, and more.

While education is undoubtedly a priority during residency, maintaining the health of both doctors and patients is equally important.  As long as these regulations can cut down life threatening mistakes, I feel that cutting back these hours can be a good thing. Medical residents will still be able to gain the experience they need to practice, and after they complete their first year of residency, young doctors will only be restricted to 24 hour shifts. Ultimately, these guidelines will improve quality of care for patients and better health for doctors and patients alike.

In 2006, Massachusetts established a broader health care system to provide universal health insurance coverage to its residents while also cutting down costs. The Massachusetts health care reform features several crucial components that expanded coverage to more than 100,000 uninsured.  The reform requires all Massachusetts adults to enroll in a health insurance plan or risk penalty, while all employers must also provide health insurance to employees or pay a penalty. Low-income adults have the opportunity to join one of the state-run Commonwealth Care plans.

Massachusetts Must Control It's Health Insurance Costs

While Massachusetts has succeeded in expanding health insurance coverage, it has not succeeded in slashing costs. As of June 2010, Massachusetts has the lowest uninsured rate in the United States at 4.8 percent, having slashed the uninsured rate by 60 percent. Compare that to the United States as a whole, where 15.4% of citizens are not covered.  Massachusetts’ efforts in expanding covered should be classified as successful.

However, the successes of broader coverage cannot hide the plan’s inability to cut costs.  The wide coverage, coupled with state subsidies and reduced rivalry between health providers, has caused costs to rise. The Massachusetts Department of Insurance has denied insurers’ demands for rate hikes in an attempt to keep expenses low for consumers. Meanwhile, insurers argue that reducing rates without slashing health provider costs places undue stress on them. Premiums have increased substantially for individuals and families, while the use of the emergency room for non-emergencies did not markedly decrease, perhaps indicating a deeper issue: the primary care physician shortage.

The similarities between the Massachusetts plan and the 2010 US Affordable Care Act make Massachusetts’ successes and failures ever more glaring on the national stage. According to a report from Fortune Magazine, both the Massachusetts and Obama plans increase health care demands without addressing health care shortages.  Prices have gone through the roof, and according to Fortune, will not decrease until the government stops targeting insurers.  Insurance pools also grow more expensive as younger, healthier members drop out while sicker members stay in.  Subsidizing middle-income plans may also prove expensive, while additional state-mandated benefits have also strained the system.  According to Fortune, Massachusetts residents have begun to manipulate the system to optimize their health insurance benefits and subsidies.

If Massachusetts can successfully manage the costs associated with its health care reform, perhaps this will bode well for the Affordable Health Care Act.  Four years into the Massachusetts plan, costs have continued to skyrocket as more residents are covered. In the current economy, controlling costs is ever more crucial to the health care industry and to the country’s economy as a whole.  Solving the primary care and health provider shortage may prove a good step in shaving down costs.

In the end, it will be the costs, not universal coverage, that determine success for both the Massachusetts and federal reform programs. I hope that both reforms can find a way to cut costs beyond placing limits on insurers, perhaps by streamlining health care overall and improving the pool of preventative

Decided in 1973, the Roe v. Wade case forbade states from establishing laws that banned abortion.  It gave women the right to have an abortion in any US state up until their third trimester.  The ruling of this case has led to an ongoing abortion debate throughout the nation.  Anthony Kennedy, a Justice of the Supreme Court, is known for having a “swing vote” in many Supreme Court decisions.  However, people fear that a Republican President may choose to replace Kennedy.  Kennedy’s vote has always been important in the abortion cases.  If he were replaced, there is fear that Roe v. Wade may be overturned. This would allow states to enact laws against abortion at any point in the pregnancy if they so desire.

Supreme Court Nomination May Overturn on Roe v. Wade

If Roe v. Wade was overturned, the likelihood that we would see any variation in the amount of abortions in the US would be slim.  More problems may arise than would be solved in the event that Roe v. Wade was overturned.  If it was, there are about 20-25 states that would immediately enact laws against abortion.  This would make it more difficult for females to find a doctor offering abortion services.  However, it would not stop them from having abortions.  Females will either go to the states offering abortion services or find other means that are less safe and healthy than finding an available doctor.  Overturning Roe v. Wade would theoretically eliminate 170 doctors providing abortion services, which is less than 10% of all services available in the US.

Overturning Roe v. Wade will pose serious health and financial burdens.  As mentioned before, females will take more risky measures to have an abortion.  Those who decide to keep their baby are immediately faced with the high hospital costs and medical costs associated with having a baby.  Consequently, more women may consider taking contraceptives to prevent pregnancy in the first place.  However, this too can be expensive because many health insurance plans do not cover contraceptives.  If they do offer coverage, there is often a high out-of-pocket charge for the contraceptive prescription.  Also, there are very few health insurance companies that offer abortion coverage (most are private insurance companies).  It is likely that these health insurance companies will establish much higher costs in the states that would choose to allow abortion after overturning Roe v. Wade.

The replacement of Anthony Kennedy is not an immediate concern, but it is a possibility in the near future.  Kennedy’s retirement should not be in question because he is not likely to retire soon.  The only imminent threat to his position would be a Republican president, who may choose to replace Kennedy with a candidate who opposes abortion.  This decision, however, would have many repercussions and may not solve any abortion issues.

A true microcosm of the United States, Connecticut deals with the issue of provider monopolies when it comes to hospital networks. We have allowed hospitals all across the country to create player unions. For example, Yale New Haven, Greenwich, and Bridgeport hospitals are banded together for contracting purposes. There is really no negotiation between these hospitals and the health plans – as the hospitals tell health plans what the price of service will be and do not let health plans charge more to patients using higher cost facilities.

Connecticut’s strict Certificate of Need (CON) laws prevent new competition from entering the market. CON approval, regardless of cost, is required for anyone acquiring, purchasing, or accepting donation of a CT scanner, PET scanner, PET/CT scanner, or similar new technology equipment (see more about the Certificate of Need Process from the department of insurance). The CON board is controlled by the hospitals, making it even more impossible for new competition to enter the market.

This market power of the hospital oligopolies is one reason why the public option is so dangerous to private insurers. A public option would reduce unit costs below private insurers and quickly put them out of business, removing competition altogether.

Investigators found yesterday that two-thirds of the health insurance industry in the United States uses a faulty database that charges patients more for seeing out of network doctors. The database, operated by Ingenix, kept rates low in order to underpay doctors which then drove up costs for patients.

Ingenix is a subsidiary of UnitedHealth Group which is also used by nearly 20 regional and national health insurers. Ingenix agreed last January to pay $350 million in order to settle allegation that it kept its rate low to underpay doctors.  Other health insurers include Aetna, CIGNA, and Wellpoint.

Health insurers submit information to Ingenix to determine the costs for care received out of network. Health insurance companies often skew data to underestimate the costs of medical services so that patients would have to pay more in out of pocket costs.

“The result of this practice is that American consumers have paid billions of dollars for health care services that their insurance companies should have paid,” states the Senate Commerce Committee’s investigative staff.

“Insurers know that policyholders are so baffled by those notices they usually just ignore them or throw them away,” said Wendell Potter, a former insurance executive at CIGNA. “And that’s exactly the point. If they were more understandable, more consumers might realize that they are being ripped off.”

To see the full report, go to http://www.google.com/hostednews/ap/article/ALeqM5g4s2x4w7hv-cWoKaCbdWmE1sQecAD991BJOO0.

As the cost health care services continue to rise in the United States, so does the cost of providing health care coverage. This can be seen in Anthem increasing base premiums for some of its Individual business under-65 plans in Virginia. The base premiums for a Plan like the Lumenos HSA standard increased by 15% while the Keycare Preferred base premium rose 13.5% and the Virginia Standard base premium rose 11%. Factors like any applicable age increase, moving to an area with higher or lower medical costs, changing the number of family members enrolled in a policy, or adding or deleting optional coverage may also affect premiums for customers. Members are required by law to be notified in writing of the increases in premiums, and are advised to to call their agent or Anthem Sales Representative if they have any questions. Anthem offers advice to its customers, some of which includes raising their deductible. They also state they offer other lower-cost plans as alternatives.

Unfortunately for many people in New England, large changes are being made to insurance plans for the upcoming year. Important changes in the way CIGNA HealthCare plans to operate in the states of Massachusetts, Maine and New Hampshire will take effect on January 1st of 2010, the next contract year. CIGNA HealthCare has decided to withdraw from the HMO market and no longer offer the HMO Plans to any sized employers for coverage of any employees and their eligible dependents in those states.

These changes affect the CIGNA HMO and CIGNA HMO Point-of-Service Plans which are currently used by employers with more than 50 eligible employees as well as the stand alone HMO only network use by New Hampshire Small Group employers with 50 or less than 50 employees. In order to help ease the transaction clients can replace their HMO/POS Plans upon renewal with one of the other plans that CIGNA will continue to offer.

Clients and their employees will be notified of this termination in writing starting with mailings scheduled for the week of June 15th.

A recent study done by J.D. Power and Associates ranked the nations best health insurance plans by areas of the United States. The study measured health plans based on seven key factors that drive the members’ overall health plan experience: Provider Choice; Information and Communication; Coverage and Benefits; Claims Processing; Statements; Customer Service; and Approval Processes. Included in the study are 131 health plans in 17 regions in the United States and the results of more that 33,000 health plan member surveys conducted between December of 2008 and January of 2009.

Headlining the results of the study is Health Alliance Plan (HAP), which was rated “Highest in Member Satisfaction among Commercial Health Plans in Michigan.” This is the second year in a row where HAP ranked highest in member satisfaction among Michigan commercial health plans. HAP earned a five star Power Circle Rating which signifies “Among the Best” in four areas: Customer Service, Overall Experience, Coverage and Benefit, and Information and Communication.

Other award recipients include: BlueCross BlueShield of AZ, AL, FL, NE, and IL, HIP Health Plan in New York/New Jersey, Harvard Pilgrim Health Care in New England, and Humana in the South Atlantic and Texas.