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Should Personal Responsibility Be Rewarded With Lower Insurance Premiums?

The time has come to change the rules. As you know the current insurance market is unsustainable. Whether you’re talking about The Medicare National Bank or your Blue Cross, they are all doomed for failure. Why? Because they treat everyone (group plans) the same . And as a result, the incentive towards health has been lost.

What if it wasn’t like that? What if your cost of insurance was 1/10 as much? What if you only paid $1000 a year in insurance, and carried an income based high deductible health policy? What if you were required to take care of the oil changes while your insurance, an affordable insurance, was there to protect you from disaster. An insurance you bought in the open market.

Is all this possible in the current insurance market? Not even close. If you are lucky enough to be employed by a big corporation, you are lucky enough to have deep premium discounts and a large population to spread the risk. If you work for a small business or are a small businessman, you are just one major illness away from catastrophic premium increases. Should you or one of your employees get sick, you’re all screwed.

If three of Happy’s hospitalists suddenly became gravely ill with H1N1 and were left on the ventilator for weeks and accrued hundreds of thousands, perhaps millions of dollars of health care bills, the cost of my premiums would rise dramatically, as a consequence of the large risk in a small pool of people, Happy’s private hospitalist group. While big business is able to spread that risk over hundreds, sometimes thousands of employees, they too are finding that they can’t keep up with the cost of health care inflation.

Why? Why does it have to be so difficult? When people are put in control of their health care dollars, they have a skin in the game that can’t be appreciated by the third party insurance model. Few people realize that the $12,000 in premiums their employer is paying, on their behalf, is $12,000 that is coming out of their pocket.

Many liberals want to claim that middle class wages were stagnant during the Bush years. Hardly, when you account for the health care premiums their employers paid on their behalf, the numbers don’t look so bad. These are stealth wages, wages which might as well be cash in your pocket.

Unfortunately, the current rules of the land have created a completely irrational playing field. Why should my choices be limited to what my employer offers or what my state says is right for me? Why should I be straddled with massive rises in insurance premiums because three of Happy’s partners had an unlucky run in with a virus? It shouldn’t have to be that way.

That’s why I see market choice and responsibility as the way out of this fiscal disaster. If premiums have doubled in the last 10 years to $12,000, how many businesses big and small can afford $25,000 in ten more years? The answer is almost none. Obama’s proposals do nothing to address this factor. The solution is not more insurance. The solution is not Universal insurance. The solution is to change the rules of the game. Rules your government created. Rules which brought us where we are today. The current insurance model does not work because our insurance has become an inflated currency of trade. A currency which is not allowed to follow the rules of supply and demand. Look only to the expansion of health care jobs in the worst recession in over 50 years and ask yourself how that is possible. And ask yourself if that is sustainable.
I do not want to be paying $25,000 a year a decade from now. $25,000 a year for taking care of myself and doing what’s right for my body.
We already know that 80% of cancer, diabetes, heart disease and stroke can be avoided by doing four simple things:
  1. Don’t smoke,
  2. Engage in 3 1/2 hours a week of exercise.
  3. Eat a diet high in fruits and vegetables and low in read meat
  4. Don’t become obese (BMI >30)

If you do these four lifestyle actions, your odds of falling ill with one of these top four life changing or life ending diseases is slashed by 80%. That is an amazing fact. To a major degree you have the ability to decide your destiny of health by the actions you choose.

That’s the insurance pool I want to be a part of. I want to be insured in a group of millions who take a personal responsibility for their health. People who have reduced their risk dramatically, and as a result, have reduced their risk of expense as well. If they still contracted a bad disease, so be it. At least they did what we know works, for most people. I want to restrict membership to those who care about their health, no matter how sick they are.

When I purchased my life insurance and disability policies, I was asked about, tested on and rated by my lifestyle characteristics. Why should health insurance be any different? Why should a smoker pay no more in a corporation than a non smoker? Spreading the risk over thousands of corporate employees is not an excuse for making poor lifestyle choices. Everyone loses with increased illness, higher sick days, and decreased productivity.

Why should a worker who doesn’t exercise and eats all day pay no more than the coworker who goes home at night, eats a light meal and goes for a 3 mile run? When that corporation treats smokers the same as nonsmokers, they end up passively raising the cost of insurance for all of us. Bad lifestyle choices lead to bad health. Corporate risk pooling is a free ticket to insurance paradise. When you treat all lifestyles the same, you remove the personal incentive to change. It’s time to take the employer out of the equation and put it where it should be. In the hands of the worker, a worker who makes the choices in how they live their life.

Some businesses are fighting back. They aren’t accepting that notion of risk pooling any more. Over at Scotts lawncare, they won’t hire you if you smoke. Is that right? Absolutely. Their employee rate of tobacco abuse has dropped 75%. Destiny or choice? You make the call. Why should a business have to play cop with their employees? Why? Because they are the ones paying the bills. And by default they should take every opportunity to reduce their health care costs and pass some of those saving on to employees by way of higher wages. Who says they will? The market does.

By treating everyone the same, business creates a race to the lowest common denominator. Imagine for a moment if all schools were required to remove their gifted programs for students who excelled because parents complained their ungifted children didn’t qualify? Should the gifted be punished because the ungifted couldn’t hack it? Of course not. What you want are more gifted students to excel, regardless of what the ungifted students are doing. The goal is to make everyone smarter, not equal. And gifted children require more intense curricula to succeed.

Why should we not put lifestyle choices into the equation of health care finance and personal responsibility? Here’s the way I see it. It’s time to remove restrictive state insurance requirements and offer market based solutions to the premium inflation dilemma. And it’s time to do it in a fair and balanced way. The current debate should not be about access. It should be about cost.

We need to create a new generation of Lifestyle Insurance options that will force 300 million Americans into a healthy submission. Come prepared with your lifestyle, or you will have to pay to play. Your government has engineered an economy that has lost millions of jobs in the last two years, in every sector except health care. In fact, the health care sector is growing strongly. What does that say to you? To me it says our current health care inflation runs on false economies, the same economies that created the tech and housing bubbles. It’s only a matter of time before the health care inflation bubble collapses.

Here’s what needs to happen. First of all, I want to be able to choose my lifestyle based insurance pool. Am I being selfish? Absolutely. Am I being fair? Absolutely. I want my gifted kid to go throught the gifted program. Should I get to choose my insurance pool based on smoking status? How about exercise tolerance? How about waist circumference or BMI? Should I have a right to choose my pool of fellow Americans based on the God given choices they make on a daily basis? Those that don’t do drugs or drink excessively?

My answer is a resounding yes. The data is compelling. How you choose to live your life plays a major role in how sick you become. If I can reduce my chances of contracting 4 of the largest causes of death and disability in this country by 80%, I want to be in an insurance pool with millions of others who are doing the same. Why should I pay $12,000 a year while my coworkers smoke, lay around and eat potato chips all day. If they want to do that, that’s their right. It’s not my duty to help pay for their self inflicted disease. That’s up to them to deal with the consequences.

Here is what I want. I want an insurance cooperative based on my lifestyle choices. I want to pay my premiums knowing that I did everything I could to keep myself healthy. And I want the reward of paying less. I want the security of having millions of like minded Americans doing the same as I across all states in this country. I want to be grouped with those that don’t smoke, those that exercise, those that maintain their weight and eat healthy. And I’m willing to sacrifice my personal freedoms to be tested by what ever means is determined to justify joining my fellow Americans who have taken a personal responsibility toward their healthy lifestyles.

I want to get rewarded by having my premiums drop and the pool of expenses decline. I want a pool of premium payers who understand that health is not given to you. It’s earned. I want people to want to join my risk pool. To earn their way in and receive the benefits of drastically reduced premiums. Reduced premiums that are earned through hard work and dedication. I want everyone to strive for the gifted program, not settle for mediocracy.

We need a dedication that should be rewarded with fire sale premium pricing, achieved through the pooling of millions of like minded individuals who take a personal responsibility toward their health, even if they carry preexisting disease states. Former smoker? Fine. Former drinker? Fine. Lots of disease? Fine with me. If you are practicing healthy lifestyles you have a right to join the group, as long as you maintain the the lifestyle requirements to join my pool. If you don’t, you’re left out to find your own risk pool to join. But know that you should be prepared to pay for that constitutional right to smoke and drink Coke and watch Oprah.

If you want to join my risk pool and make me subsidize your diabetes, heart disease, stroke and cancer, because you continue to smoke, eat Cheetos and watch Oprah all day, that’s not fine with me. If you want take personal responsibility for your health, come join me in the new Era of Lifestyle Insurance Options.

As a member of a Lifestyle Insurance Plan, I would agree to the rules of the game. I would submit to random nicotine testing. I would submit to voluntary exercise tolerance testing. I would submit to BMI and waist measurement calculations. I would submit to lifestyle choice testing of any kind that offered me insurance with dedicated individuals, regardless of their preexisting conditions. I would do whatever it took to achieve premium pricing on my insurance.

If I was an employer I would offer one insurance plan to my employees. The Platinum Plus Lifestyle Plan. I would offer to pay 100% of that premium and nothing more. If you choose a more expensive lifestyle, the rest of the burden is on your shoulders.

And that’s exactly how it should be.

*This blog post was originally published at A Happy Hospitalist*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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