Ten EHBs and A Provision

There's a lot at stake for us as our elected officials try to reform healthcare. We should all understand what it means when the newspapers say they are removing this or that requirement from a proposed bill, and since it appears that Congress will continue its efforts toward healthcare reform, I wanted to discuss some of the things that will make or break their efforts, things that will affect you, no matter what condition(s) you have, or even if you have no condition at all. (Read about the first effort to reform Obamacare here.)

It’s hard to believe that it’s only been seven years since Obamacare, or the Affordable Care Act, was passed. Before that, insurance looked very different than it does today. The main reason for that is that Obamacare mandated that certain things be covered in every plan. One of the things on the table is the removal of all the Essential Health Benefits (EHBs) in an effort to control costs.

This would control costs by severely reducing the number of people covered by insurance. Those people would not see a doctor as often, potentially losing control of their conditions, and would end up going to the more expensive emergency room as a result. (Emergency rooms can’t legally turn patients away, regardless of their ability to pay, and unpaid hospital bills default to the taxpayer.)

How many EHBs have you used over the course of your condition? (I will mark all the ones I’ve used.)

  1. Outpatient care – all your doctor visits where you don’t have to stay overnight.
  2. Emergency room visits
  3. Hospital treatment for inpatient care
  4. Prenatal and postnatal care -- maternity care preceding and after birth of baby. This is an important one because in the bad old days, pregnancy wasn’t covered at all. Since the majority of insurance policies cover ‘accidents and illness,’ and pregnancy is neither accident nor illness, it didn't qualify. Pre-natal wellness visits, blood tests, recovery, and more were paid for out of pocket. Not to mention that the baby sometimes wasn’t covered for the first 10 days, so that if there was something wrong, it would be classified as a pre-existing condition, which is also not covered.
  5. Mental health and substance abuse services, drug and alcohol rehab. This is the rule that helps people with opioid addiction and veterans with Post Traumatic Stress Disorder.
  6. Prescription drugs – no explanation necessary.
  7. Rehab and rehabilitation services and devices -- to aid in recovery in case of injury, disability or chronic condition, including physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8. Lab tests
  9. Preventive services, including counseling, screenings, and vaccinations and care for managing chronic disease – annual physicals, Pap tests, mammograms, colonoscopies, etc.
  10. Pediatric services, including dental and vision for children.

That's nine out of 10 for me.

Now the provision that pulls it all together, because even if you have access to all of the EHBs, if they're too expensive, access doesn't matter. The 'community rating' provision of Obamacare says that people with pre-existing conditions don't pay more for coverage than their healthier peers. It says that no one in a set geographical area (community) can be charged more than anyone else in that area for the same amount of healthcare coverage, regardless of circumstances like gender, occupation, industry, weight, claims history, or most important to us, health status (pre-existing conditions). Right now, the only factors an insurance company is allowed to consider are family size, age, geographic location, and tobacco use.

In a relatively short time, these regulations have become important to us. They allow us a higher quality of life. How much more would you have to pay for your condition if the EHBs and community rating provision were eliminated? If you feel strongly about keeping the above provisions, tell the people in charge of the reform effort, and not just on Capitol Hill. Rumor has it, some states are moving forward without Washington.

(Here is a link to Project Vote Smart, which will tell you who works for you, from the president right down to local judges.)

Conversations with a Retired Healthcare Executive (Who Just Happens to be My Father)

Chapter 2: How do they figure out what plans to offer and how much they cost?  

Health insurance plays an outsized role in our lives. But does anyone really know how it works? Or, for that matter, what it really says? In this series, I will be talking to my dad, a retired healthcare executive, about a variety of topics to get some clarity on private (employer-supplied) health insurance.

Jeremy Sachs spent 30 years working for a Fortune 500 insurance company. During much of that time, as House Counsel for the Employee Benefits Division, he advised corporate managers of the Division on a wide range of legal issues relating to the Company's group health insurance policies, including during the times when the Health Insurance Portability and Accountability Act (HIPAA) and the Americans with Disabilities Act (ADA) were passed and instituted.

This series does not apply to Medicare, Medicaid, Obamacare (The Affordable Care Act, or ACA), or individual health insurance, unless otherwise specified.

The Players

Insurance Company

  • Sales Rep/Marketer—liaison between the insurance Company and your employer
  • Underwriters – determine the risks involved for each policy
  • Actuaries – mathematicians who determine the cost of a policy

Your Employer

The Process

Negotiations for a new health insurance policy or an update to an existing policy are long and complicated

They start with your employer. The insurance company’s sales rep sits down with your employer’s Benefits Manager and negotiates what your employer wants included in the insurance policy: what level of risk the insurance company is willing to take; what the deductibles will be; the method will be for computing a provider’s “reasonable and customary (R&C) charges”; and, what percentage of those R&C charges the company wants to cover. (That’s when the policy says they will cover 80% of reasonable and customary charges after the deductible or 70% of psychological therapy visits.)

Once the insurance company knows what the employer wants in the policy, the representative collects certain types of information about your employer, including:

  • Type of work (office/manufacturing/labor/academic/government, etc.)
  • Number of employees
  • Type of employees and percentages (skilled, management, executive, etc.)
  • Employee retention (In the insurance industry, employees who stay at their jobs longer may suggest a more stable lifestyle – that is, employees who keep a job for only a short time, and then move on are considered higher risk.)
  • Claims history from previous years. (A Group Policy issued to a brand-new company may cost more, since the Insurer will have to guess how high the first yearly payout of claims will be.
  • Company financial stability

And about you. Since it’s illegal to ask specific employee health questions, the insurance company will ask questions about the members of the group:

  • Gender
  • Age
  • Race/Ethnicity
  • Percentage who have dependents.*
  • Other general demographic questions

* Dependents are important because their – both children and spouses – costs are calculated at a higher rate than that for the primary insured. This is because since employees come to work on a regular basis, they are assumed to be generally healthy. But no such assumption can be made for dependents. Spouses and kids, as a group, tend to have more or higher claims than employees. (The kids I know definitely get sick or injured more often than the adults, but I am not sure why the spouses do. Dad didn’t know, either.)

These and other factors are all thrown into equations when the insurance company calculates the cost of the individual benefits offered in the policy, and the premium for the policy overall.

Once the sales rep has collected all the information from the employer, they send it to the underwriters. Underwriters determine how risky it will be for the Insurer to cover the group.  Keeling over from a heart attack is more likely in a sedentary cube farm than on an active factory floor. But losing a finger is more likely on a factory floor than in a cube farm. Unless you’re using the copier wrong.

Or, if the Company is located, say, in Florida, the group may have a more employees with respiratory conditions than in, say, in the Colorado Rockies, where the air tends to be purer. 

The underwriters start with “standard rates”. They take the gathered information and use complicated algorithms to determine how much risk of a claim is likely for each type of coverage that the employer wants in the policy. They then assign higher degrees of risk for any elements of the group that don’t fit the algorithm.  Then they send their calculations to the actuaries.

The Actuaries are the mathematicians who figure out how much to charge. Actuarial tables are always being updated. As treatments and knowledge around a condition improve, probabilities of severe consequences are adjusted and sometimes costs go down. But there are also new conditions that can’t be treated that have to be factored in. They create their own algorithms around the Law of Probabilities -- that you will need X treatment, based on current national or local (industry) claim experience. They create rates to be charged to the group based on a series of calculations of the probability that employees and dependents, as a group, may at some point need all or most of the insurance for the conditions covered by the policy. Then they figure out the rates for your employer’s Group Policy. 

With the rates in hand, the sales rep for the Insurer finally presents the policy package to your Benefits Manager. The package includes rates, definitions, and descriptions of what will be covered. These are the sections that specifically explain the insurer’s LIMITATIONS on what’s covered and lists of the risks that it will not cover at all (EXCLUSIONS), as well as a whole host of administrative requirements and other explanatory material.          

A squeaky wheel can impact your insurance policy.

So, after two pages, why does all this matter? Because you’re not as powerless as you think.

There is a long negotiation involved once the initial figures are given. Both sides are worried about competition. Insurance companies don’t want to lose clients to another insurance company because of lower prices, and your company doesn’t want to lose good employees to a competitor with better benefits. 

And that doesn’t even touch on unionized industries. Unions will often negotiate on the cost to employee and breadth of coverage. Like better maternity coverage for a younger employee pool or better rehab coverage for an older employee pool.

So, if you have an opinion, tell your employer. Start with the Benefits Coordinator or someone in Human Resources for companies that aren’t big enough to have a Benefits Coordinator. We had issues a few years ago with the pharmacy provider my company was using, and after a few years, there were enough complaints that my employer switched providers. [CS1] 

It’s not a guarantee, but it never hurts to speak up.

Bonus:

Every policy has an incurred but not reported (IBNR) reserve for health insurance claims, commonly referred to as a ”tail.” The tail covers late claims submissions. Sometimes I just don’t have the time and energy to submit claims, especially the out of network ones, so I wait until I do. The tail, based on the size of the policy, covers those late filings. The length of this grace period, called the IBNR runoff, varies with the policy, but is often six to twelve months. So don’t give up on reimbursement if you’re a little late. Know your IBNR runoff period, and give yourself a break.

So, Why Yet Another Blog? And Why This Blog?

Because if you have an autoimmune or chronic condition, the likelihood is that I have been where you are. 

When you were diagnosed, were you scared? Bewildered? Confused? Angry? Numb? Did you feel helpless or stupid? I was too young to understand completely, but I remember clearly how angry I was. Very angry. Furious. I didn't know then that it was a defense to cover helplessness. It was so big. DIABETES (it always seemed weird that it's never capitalized in print). I didn't know what it was, how it worked, or what it meant for the rest of my life. Everything was changing. I thought, what do I do now?

There was other stuff, too -- subconscious stuff. I didn't realize it until recently, but I also felt a deep sense of betrayal. It makes sense. What's worse than when you betray yourself? And what else can you call it when your body turns on you and literally attacks itself? You are supposed to be able to trust yourself more than anyone else on the planet, right? But you can't. Nothing works like it's supposed to anymore. 

My situation was made even worse by the fact that I thought I had already paid my medical "dues." You know those commercials for the meningitis vaccine? I had that. Eight years before my diabetes diagnosis, I got B strep meningitis. I was the only kid who survived it that year, and even then I ended up in a wheelchair for 18 months. It was only through my family's support and sacrifices that I won that vicious, ugly war.

It was a real slap in the face to realize that wasn’t the end of it, that instead of winning a war, it had just been the opening salvo, a mere battle in a conflict that would last the length of my life.

Decades later, it makes me sad sometimes to think about who I might have been if I had been healthy. Then I think about how far I've come. Yes, my conditions (I have several now) are hard. Inconvenient. Time-consuming. But I like the life I have and the person I have become. I am proud of the strength that came from the crucible of my medical issues. I am grateful for the relationships I have, every one of which is worthwhile and valuable (you tend not to waste time on superficiality when your time and energy are limited). And maybe, just maybe, I have learned enough to trust myself again.

So, why this blog? I want to use my experience and contacts to arm you with the tools you will need to navigate both your condition and our ridiculously complicated healthcare system. I figure that if I can help just one person avoid my mistakes or come through the low points better than I did, I can consider this a successful venture.

The Challenges of an Invisible Condition

Most of the people reading this blog have conditions that are invisible. If I had a nickel every time I heard, “you don’t look sick,” I wouldn’t be driving a teenage Honda. I am always pleased to hear it, as it is a testimony to my good control, at least most of the time.

But, no matter how “normal” I look to others, the fact is that I have a lot more mandatory work to do to live every day than the average human being. For example, I can’t just skip a meal when I’m not hungry. I have to either alter my insulin or make adjustments so my body doesn’t get mad at me (yes, sometimes I think of my physical self as a separate entity with its own agenda, especially when I have blood drawn and my veins run away, like they’re playing hide and seek). This might not matter most days, but when it does, it REALLY does.

How do you explain to a boss that no, you don’t have a fever, and yes, you are probably functional enough to work from home, but you can’t come into work today because you have to deal with the side effects of your condition? I do not like to be around people if I just can’t get my blood sugar down. It’s a very vulnerable place to be. I feel like crap and I am scared because I can’t figure out what’s going on. Also, I like the people I work with, but not enough to let them into that particular corner of my life. If nothing else, it would totally undermine their view of me as a competent co-worker.

Or how do you handle the looks you get if you park in a handicapped parking space, but you don’t look handicapped? The world has a lot of righteous judgment for people they’ve never met.

Then there are the times, especially if you are seeing a provider who doesn’t know you well, when you feel like you have to justify the reason for your visit. I remember going to see my GP—who does know me well—for a sore throat that had lasted upwards of three weeks before I went to see him. I’d been checking my temperature and it didn’t seem like I had much of one, especially since I tend to run about a point lower than average, so 98.6 is actually high, more like 99.6. When he checked my throat, I told him I wished I’d come earlier in the day because it didn’t hurt in the afternoons as much as it did in the mornings, and I assumed the inflammation would be more visible. He told me I didn’t have to justify myself, that he  believed that I had what I said I did. I think I almost cried, which is not something I do publicly. Ever.

I have always coped by leading with my chin—thick skin, don’t care what others think, defensiveness as an end in itself. This is not a position I would recommend. It can be very isolating. To give you an idea, the people who are closest to me aren’t there because I invited them in; they are there because they thought I was worth the effort of pushing past that rough exterior. They have stuck with me through a lot, and I will never be able to express how grateful I am for their friendship.

I think... I think that the healthiest way to cope is to accept that everyone has their own version of normal. You can share as much or as little as you are comfortable with. But without your health, you have nothing. Don’t push yourself so hard that it affects your condition. Accept help from the people who love you. Teach them how. They are your safety net. And know that there are going to be days when you have to put yourself first. This is not something to be ashamed of, it just is.

How did Henry David Thoreau put it? “I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived. I did not wish to live what was not life, living is so dear; nor did I wish to practise resignation, unless it was quite necessary. I wanted to live deep and suck out all the marrow of life, to live so sturdily and Spartan-like as to put to rout all that was not life, to cut a broad swath and shave close, to drive life into a corner, and reduce it to its lowest terms...”[1]

 It’s hard to hear, but our lives are limited. Do what you need to do to get as much as you can out of what you have.

[1] http://www.goodreads.com/quotes/2690-i-went-to-the-woods-because-i-wished-to-live

 

Your Life as a Car

This blogpost is by Debra Hein. Debra is a Personal Trainer of over 25 years, specializing in people with conditions (diabetes, cancer, heart disease, etc.). She has a Bachelor of Arts in Exercise Science and is a Certified Exercise Physiologist (CES), Certified Personal Trainer (CPT), and American Heart Association Certified Instructor. Deb is my trainer. She can catch fluctuations in my blood sugar before I do.

I have spent hours trying to start this article so it would not be just another article about the importance of exercise, disease prevention, and health. As a trainer, I have always used the analogy of a car engine and your muscle mass to describe burning calories. The larger the car engine (muscle mass), eight cylinders vs. four cylinders, the more gas (calories) you burn to travel the same number of miles. Expanding on this will show the effects of a sedentary lifestyle on the human body.   

Think of your body as a shiny new car – your choice. I will use one of my favorites, a 1957 corvette. Let’s set up the analogy to the human body with a list of parts:

  • Car: human body
  • Gas pump/carburetor: human heart
  • Hoses and fuel lines: arteries, veins and lymphatic system
  • Gas, oil and other fluids: blood, lymphatic fluid and food/nutrition
  • Number of engine cylinders: muscle mass
  • Engine/computer system: brain
  • Driving: exercise
  • Mechanic: doctors  

Sixty years ago, this was a brand new car with a clean engine, new tires, and a pretty new paint job. It ran like a dream, and the owner was happy to drive it every day. By driving the car every day (exercise), the engine (brain) would get the gas, oil and other fluids (blood and bodily fluids) pumping through the car (body) to move the cylinders (muscles) and make the tires move the car. Everything would work well if the owner made sure the fluids were kept clean, gas tank was filled (nutrition), and the car was brought in to the mechanic (doctor) for regular tune ups. Rarely did the corvette need to go to the mechanic (doctor) for more than regular visits (annual checkups). 

As the years passed, the owner’s needs changed, family size grew, and this shiny new car spent more time in the garage (sedentary). The car was not driven (exercised) every day, and soon, things began to break. The battery (motivation) died and had to be replaced. Once the car started, she ran well, but there seemed to always be something that needed to be checked. Annual tune ups were no longer good enough.

By now, the corvette had logged thousands of miles; hoses and tires needed to be replaced, and other parts began to show wear (signs of aging including sports injuries, etc.). The paint became a little dull (body added a few pounds) and didn’t quite have the sex appeal as in years past. Trips to the mechanic became more common because of age issues with the car.

Eventually, to keep the car on the road, expensive replacement parts needed to be found. The type of fuel used when the car was new was no longer available and special additives (drugs) were needed in order for it to run properly. The end of the corvette’s days was slowly approaching. The lack of use (exercise) was too much and the gas/fuel pump and lines rotted (atherosclerosis). The car needed a whole new engine. At that point the cost of upkeep became very high (increasing medical cost of aging).

This is what happens to your body over time. 

Study after study shows the importance of movement and activity in our lives. Not only for weight control, but for heart health, brain activity, muscle function and strength, controlling our body functions, and overall wellbeing. See below for a table on common diseases and the impact exercise can have to help prevent, postpone and control symptoms and responses. Just like cars, our bodies are born to run. 

Disease/condition

Recommended cardio activity

Type

Recommended strength activity

Benefits/responses

Coronary Heart Disease (CHD)

>3 mph (40-80% HR)

30-60 min

5-7 days/wk *

Rhythmic large muscle groups

2-3 days/wk

Each major muscle group

30-40% 1-RM^ for upper

50-60% lower exercisers *

- Improves aerobic capacity

- Increases muscular strength

- Lessens of angina symptoms

- Raises ischemic threshold

- Improves endothelial functions

Hypertension

High BP

>3 mph

30-40 min

5-7 days/wk

Use caution for heavy lifting and isometric resistance exercises

60-75% 1 RM

2-3 days/wk

All major muscle groups

- Reduces Systolic BP^^ 4-9 mmHg

- Reduces weight, which results in additional SBP reduction

- Reduces vasoconstriction - Reduces peripheral vascular resistance

High Cholesterol

Dyslipidemia

40-75% HR

40-70% HR***

- Reduces LDL 4-7%^^^

- Increases HDL 4-25% **

- Reduces adipose fat

Pulmonary Disease

Start with 3-5 days/wk working towards 5 days/ wk

Intensity will be individually determined based on individual’s response.

2 days/wk

Individually determined based on individual’s response.

Depends on disease, severity and individual responses

Diabetes

5+ days/week

Varies for Type I and Type II

2 days/week

Varies per individual

- Enhances insulin sensitivity

- Increases cardiovascular fitness

- Improves glycemic control

Arthritis, Osteo and Rheumatoid

3-5 days/wk

30 min or more

Intensity varies by Individual.

Rhythmic large muscle groups – walking, cycling, water workouts ++

2-3 days/wk working all major muscle groups – 8-15 reps

Yoga/Tai Chi++

Intensity will be based on individual level+++

- Improves range of motion, flexibility, aerobic endurance, muscle strength+++

Please note:

^Repetition maximum (RM) is the most you can lift once. So, when it says 30-40% 1-RM, that means for your set of weightlifting, you should use a weight that is 30-40% of the most you can lift once. 

^^Systolic blood pressure (SBP) is the bottom blood pressure number.

^^^LDL is bad cholesterol. HDL is good cholesterol.

Sources:

*LaForge, R., M.S. (2015). Coronary Heart Disease. In Medical Exercise Specialist Manual (p. 202). San Diego, CA: American Council on Exercise

**LaForge, R. M.S. (2015) Blood Lipid Disorders, in Medical Exercise Specialist Manual (p. 224) San Diego, CA: American Council on Exercise

***Galati, T., M.A.  (2015). Applying the ACE Integrated Fitness Training Model in The Medical Exercise Setting In Medical Exercise Specialist Manual (p. 50). San Diego, CA: American Council on Exercise

$ LaForge, R., M.S. (2015). Coronary Heart Disease. In Medical Exercise Specialist Manual (p. 188). San Diego, CA: American Council on Exercise.

$$ Kenney, W.L., Ph.D., & Alexander, L.M., Ph.D., (2015). Hypertension in Medical Exercise Specialist Manual (p. 254, 259, 264). San Diego, CA: American Council on Exercise

+ Riddell, M., PhD, & Perkins, B. A., M.D., M.P.H., FRCP. (2009). Exercise and Glucose Metabolism in Persons with Diabetes Mellitus: Perspectives on the Role for Continuous Glucose Monitoring. Journal of Diabetes Science and Technology From Basic Science to Clinical Practice, 914-923. Retrieved March 11, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769951/.      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769951/ 

++C. N. (n.d.). How to Start an Exercise Program. Retrieved March 12, 2017, from http://www.arthritis.org/living-with-arthritis/exercise/how-to/starting-exercise-program.php

+++ Aronen, J.G., M.D.,FACSM & Lorenz, K.A., Ph.D., CSCS, NSCA-CPT, (2015) Arthritis in Medical Exercise Specialist Manual (p 544). San Diego, CA. American Council on Exercise