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U.S. health system’s huge improvements


Jeff Goldsmith, Ph.D.,  president of Health Futures Inc. and associate professor of public health sciences at the University of Virginia, says in a Hospitals & Health Networks piece that U.S. health-system performance has gotten better in recent years.

He gives a lot of attention to total hip replacements, wh0se “breakthrough” started in the mid-1970s.

“There has been no cure for arthritis since and, sadly, none appears even remotely likely. Rather, the real progress in total hip replacement came from continual refinement by the orthopedic community not only of hardware but also of clinical processes inside and outside the operating room.”

“Nor is this seemingly invisible progress through collective learning an isolated instance confined to orthopedics.  Much has been made of the continued frustration in the search for a ‘cure’ for cancer and of the high cost of new cancer medications. The popular press neglects to mention that while we’ve been waiting for a ‘cure’ for cancer, there has been a nearly 25 percent decline in the age-adjusted death rate from cancer in the U.S. since 1990.”

“Though the disease remains scary for patients and their families, cancer treatment today is much less a ‘one off’ search for solutions than it was even a decade ago. Cancer care is increasingly protocol-driven, informed by a comprehensive and growing cancer registry maintained by a network of National Cancer Institute-designated community cancer centers. There has certainly been therapeutic progress for some forms of cancer, including a vaccine for cervical cancer, but the real progress has been an immense and largely invisible collective effort by the cancer community to harness the power of big data and clinical practice experience across millions of cases.”

And:  “Stroke care today begins in the ambulance on the way to the hospital, and hospitals are publicly rated on the number of minutes that elapse between the moment the patient reaches the hospital’s front door and the time that catheter-driven therapy (coils or stents) addresses the cause of the stroke (e.g., bleeding or vascular blockage). Strokes are still a scary health risk, but a massive amount of suffering and brain damage today is avoided by more systematic and focused care. ”

“Though it is still the nation’s leading killer, deaths from heart disease have declined by two-thirds since 1970. This is despite the escalation of cardiac risk created by the obesity epidemic and the resulting sharp rise in the prevalence of diabetes. Absent these two linked developments, one suspects the decline in cardiac mortality would have been even more striking than what we have seen. Twin revolutions in invasive cardiac care — bypass graft surgery beginning in the early 1970’s and cardiac stenting in the 1990s — helped alleviate symptoms, while marked improvements in cardiac intensive care saved hundreds of thousands of lives after cardiac events. ”


Some employers paying lump sums for employees’ care episodes


for Kaiser Health News

Insurance policies that pay a lump sum if workers get cancer or another serious illness are being offered in growing numbers by employers. Companies say they want to help protect their workers against the financial pain of increasingly high deductibles and other out-of-pocket costs. But it’s important to understand the limitations of these plans before buying.

Critical-illness plans have been around for decades, but they have become more common lately as employers have shifted more health care costs onto their workers’ shoulders.

Forty-five percent of employers with 500 or more workers offered the plans last year, up from 34 percent in 2009, according to benefits consultant Mercer. Employees are generally responsible for the cost of coverage, although in some cases bosses contribute to the premiums.

“What we have seen is a very clear and steady rise in the number of employers offering high-deductible plans,” said Barry Schilmeister, a principal in the health and benefits practice at Mercer. “More employers are looking at the reality of pulling back on the value of health plans but looking to offer something else that would make people feel a little more comfortable about taking on that additional risk.”

Forty-six percent of workers covered by insurance on the job faced a deductible of at least $1,000 in 2015, up from 22 percent in 2009, according to the Kaiser Family Foundation’sannual survey of employer sponsored coverage. (KHN is an editorially independent program of the foundation.)

Critical-illness policies typically provide a lump sum if someone is diagnosed with cancer, heart attack, stroke, kidney failure or needs a major organ transplant. They may also pay benefits for other medical problems such as loss of vision or paralysis; plans have an average of 19 eligibility triggers, according to a market survey by Gen Re, a company that offers insurance to insurers to help manage the risk from underwritten policies. In addition, some employers also offer a policy that pays only in the event of a cancer diagnosis.

Nine out of 10 critical-illness policies are sold through the workplace, according to Gen Re. These plans provide an average $15,000 payout to workers diagnosed with one of the conditions covered under the policy. Plans sold on the individual market pay $31,000 on average, Gen Re said, but applicants generally have to go through medical underwriting to qualify. Employer plans usually don’t require that.

The average annual premium was $283 for $25,000 worth of coverage in 2013, according to financial-services research company LIMRA.

In addition to deductibles and cost-sharing for pricey drugs and treatment, the payments can be used to help cover many expenses associated with serious illness that even generous employer health plans don’t cover, including travel costs to see a specialist, time off from work and extra charges for out-of-network doctors or hospitals.

But benefits from the critical-illness policies can be limited by very specific requirements, so it’s important to understand the coverage before you buy. Here are some of the details to look for:

Pre-Existing Conditions

If you’ve had cancer or a heart attack in the past, check to see whether the plan will cover those conditions in your case or impose a waiting period before doing so.

Excluded Benefits

“Understand that maybe not every cancer and heart attack is covered,” said Stephen Rowley, vice president at Gen Re. For example, non-invasive prostate or breast cancers may be excluded from some policies. However, a growing number of critical illness insurers are covering such early-stage cancers, said Karen Terry, assistant managing director for insurance research at LIMRA.

Partial Payouts

Rather than excluding coverage altogether, plans may make a partial payout for things like non-invasive cancer, heart-bypass surgery or angioplasty.

One-Time vs. Repeat Payouts

If you get cancer a second time, will the plan pay out again, in full or in part? Does it matter if the second incidence is the same or a different type of cancer?

Unrestricted vs. Specified Schedule Of Benefits

Critical illness policies typically pay out a lump sum to use as the policyholder wishes. Cancer policies may do the same or pay set amounts for hospitalization, chemotherapy or radiation treatments, for example.

Age-Related Benefit Reductions

Some plans reduce how much they pay out after policyholders turn 65 or 70.

Waiting Periods

Plans typically won’t pay benefits for 30 to 90 days after a policy becomes effective.

As people’s financial exposure for medical care has increased, “they’re really spooked, especially when they’ve had a serious illness in their family, and they know all that goes along with that,” said Bonnie Burns, a longtime consumer-health advocate and a policy specialist with California Health Advocates, which assists Medicare beneficiaries. “I think these [coverage] holes are going to proliferate and people are going to fill them where they can.”

However, some researchers suggest that the increasing interest in critical-illness policies does not compensate for less generous health insurance policies. “Why don’t they just offer people a better [health insurance] policy in the first place?” said Karen Pollitz, a research fellow at the Kaiser Family Foundation.


Using market-segment targeting to cut costs




Futurist Joe Flower asks if prevention actually saves the healthcare system money. He concludes in this piece: “The answer to our more targeted question is yes, there are multiple ways that we can keep the costs of disease down by providing earlier, better, smarter, more-efficient care — and we can and will discover those ways when we are more at risk for the overall health care costs of the people we serve.”

“If we are in any way at risk for the costs of their health care, the people we serve fall roughly into four categories:

  1. “Healthy people whom we would like to keep healthy, to keep them out of the more expensive categories.
  2. “People with undiscovered illnesses or risk factors that we would like to discover and treat, to keep them from migrating up the cost scale.
  3. “People with multiple chronic illnesses or major risk factors. These people likely are already in that top 5 percent or are apt to jump into it. We would hope to migrate them down the cost scale through some serious attention and careful medical management.
  4. “People with serious illness such as cancer, or major trauma. They are — and should be — in the top 5 percent.”

Mr. Flowers suggests costs can be contained by “a multi-pronged prevention strategy based on market segmentation, which I often call ‘targeting.”‘

This strategy would include:

* Encouraging healthy communities.

* Providing screening.

* Targeting high-risk groups.

* Building trust and direct human connection into  targeted programs.

* Targeting people with multiple chronic diseases.

* Building strong primary-care relationships.

* Changing practice and referral patterns.


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