Population health, public health, community health — What difference does the terminology make?

Since the term "population health" was coined by David Kindig, MD, PhD, and Greg Stoddart, PhD, in 2003, there has been so much discussion about what it means in regards to healthcare delivery that the buzzword has become something of a linguistic eyeroll.

"For many in the healthcare delivery sector, the term 'population health' represents either the holy grail of effective healthcare delivery or is regarded as nothing more than the latest flavor of the month," said Leonard H. Friedman, PhD, professor and director of the Department of Health Policy and Management MHA degree programs at Washington, D.C.-based George Washington University's Milken Institute School of Public Health.

Some thought leaders in the healthcare industry just can't seem to get passed the semantics of "population health." In April, Dr. Kindig addressed the issue by writing a blog to suggest a second definition for the term. In June, the Milken Institute conducted a survey of 37 healthcare leaders about what population health means. And every day, I run into the debate of how to use the term in my own writing as a healthcare reporter — begging the question, are more terms needed to differentiate between population health genres?

Within the strategic focus Dr. Friedman described — the transition from individual care to care for whole communities — there are two main approaches to population health, according to Roy Beveridge, MD, senior vice president and CMO of Humana.

"Some people think about population health as just a payment methodology — they think about shared savings and reducing costs around the edges," said Dr. Beveridge. "When I think of population health, and when Humana does the same, we're talking about managing not just the periphery, but taking care of a population on a long-term basis and really affecting the health of that group."

Dr. Beveridge gave the example of caring for Type 2 diabetes patients. Using a financially driven definition, population health would mean considering the least expensive insulin or treatment plan. Using a broader, community-focused definition would mean trying to influence diabetes patients to make healthier choices regarding their nutrition and physical activities.

Even this example, however, demonstrates how multiple terms describing population health can get out of hand, even if it's well-intentioned. For some hospitals, the greatest population health challenge is diabetes, for others it might be drug abuse, homelessness or violent crime. If the industry began creating terms for every "type" of population health — financial, community-focused or otherwise — we could spend the rest of eternity hung up on the words rather than real actions that could improve peoples' health.

So does the industry need more definitions for "population health," or more terms in our lexicon to differentiate between various population health efforts? No. What the industry needs is to forget the semantics and just work on transitioning its strategic focuses from individuals to whole communities.

"The bottom line is that whether we use the term population health, community health or something else, all the stakeholders in the provision of healthcare must work together with the patient to keep people as healthy as possible over their lifespan," said Dr. Friedman.

Why Was I Charged for Preventive Care?

Under the Affordable Care Act, most insurers must cover the full cost of preventive care such as checkups, vaccinations, and screenings. But many people end up surprised when the doctor visit they thought was free suddenly comes with a bill. What gives?

Here are five things to think about to avoid surprise costs at your next doctor’s appointment.

1. Know what’s considered preventive: The Affordable Care Act requires most insurers to cover the full cost of many preventive services with no co-payments or other out-of-pocket costs. (If you have a grandfathered health plan, however, this requirement does not apply.)

Preventive services include vaccinations, annual well-visits, colonoscopies, cancer and other health screenings, which in most cases are available free of charge. You can view a full list of preventive services at Healthcare.gov.

2. Pay attention to the details. The guidelines for preventive services are set by the U.S. Preventive Services Task Force, a panel of health care experts. It’s not enough to look for the services the task force recommends; you also need to be mindful of the specific guidelines of each service.

For example, although colonoscopies are a recommended preventive test, the guidelines state that it’s only preventive for people 50 and older when recommended by a physician. If you go for a colonoscopy at 40, the test likely won’t be considered preventive, and you’ll be charged.

3. Know your health plan’s rules. Health plans have some flexibility when it comes to interpreting the guidelines.

For example, mammograms are a preventive exam recommended every 1 or 2 years for women over 40. That means your health plan may pay for the test each year for women over 40, or it may only pay for the test once every 2 years. You need to confirm your plan’s coverage guidelines.

4. Provider networks matter. Even if the nature of your visit is preventive, if you go to a doctor outside of your plan’s network, all bets are off. You can be charged for the visit.

5. Medical complaints aren’t preventive. Even if you’ve gone in for a well visit, once you ask the doctor to examine you for the headaches you’ve been having for the past 6 months or to check on your stomach troubles, the visit is no longer preventive and you’ll be charged.

You can avoid unexpected bills by being clear with your doctor’s office about all the reasons for your visit when you make your appointment.

Have you been surprised by a bill for what you thought were preventive services? Please share your experience in the comments section.

Smoking Driving Up Health Insurance Costs

The American Cancer Society marks the 36th Great American Smokeout today by encouraging smokers to make a plan to quit smoking.  This gives many smokers the motivation to start their path towards a healthier life.  Not only will quitting decrease their cancer risk, but it can end up saving them money on life and health insurance quotes.

The AlliedQuotes article “How the Effects of Smoking Are Driving Up Costs” points out some interesting facts about smokers and health insurance costs.  The Union Camp Corporation evaluated the health costs of 700 of their employees in 1992 and discovered that employees who did not smoke cost their company about $462 less in health care costs than employees who did smoke.  Among the 400 production workers, each nonsmoker saved the company about $284 in sick pay.  Another study of 2500 postal workers published in the American Journal of Public Health found that the rate of absenteeism was 33% for smokers.

These shocking numbers make it obvious why employers and health insurance companies want to charge smokers more for health insurance coverage.  Unfortunately, the costs typically get spread out among all policyholders which will mean higher health insurance rates for everyone.  While an individual policy may end up more expensive for a smoker, plans through employers are typically the same for everyone.  Some employers will offer cessation programs, not only to help the absentee numbers, but also to drive down the costs of health insurance packages for all employees.

Gratitude May Be Great Medicine

HealthInsuranceSort.com is hoping everyone had a wonderful Thanksgiving season and is here to point out the importance of gratitude on our health.  John Tierney writes about this in his article on NYTimes.com “A Serving of Gratitude May Save the Day”.  According to the article, an attitude of gratitude has been linked to better overall health, better sleep, higher satisfaction with life and kinder interactions with others.  A recent study reports that feeling appreciative even makes people less likely to turn aggressive when provoked.

If your interested in better health and possibly lower health insurance quotes, listen to the advice of Robert A. Emmons of the University of California who offers techniques for cultivating gratitude.  First, don’t confuse gratitude with indebtedness.  Indebtedness can be a negative emotion bringing about negative responses.  Another tip is to pay it forward.  When someone brings an act of kindness upon you, pass it on to someone else.  Kindness is contagious and breeds gratitude.

When you are faced with negative interactions from friends and family, don’t counterattack.  Practice empathy and focus on what you are thankful for.  Studies show you will be less bothered by negative interactions if you are practicing gratitude.  You can practice gratitude by making a list of everything you are thankful for or writing a letter to someone you are very thankful for and someone who had a strong positive influence on your life.  Taking the time to really focus on what we are thankful for this holiday season may be just what we need to keep our health in check as we enjoy food, drink and good company.

Does Health Insurance Cover Weight Loss Surgery?

With the obesity epidemic going strong across the US, more and more Americans are choosing weight loss surgery as a way to get their obesity under control.  This is a big decision which should be gone over in detail with your doctor and health should be carefully considered.  The other thing to consider is the cost.  It can be very expensive coming in at around $20,000 give or take thousands of dollars.  Many individual health insurance companies will cover the surgery with a letter from the patients doctor stating medical necessity, but this varies greatly from state to state and from insurer to insurer.

The MAMSI UnitedHealthcare website talks about how to choose a hospital for bariatric surgery and what key factors to look for.  The medical community has been analyzing for years the factors that can predict good outcomes from the surgery and the education and training of the surgery seems to make a big difference.  The hospital should also be able to accommodate certain situations such as the ability to deal with obese patients appropriately.  There should be a specially trained anesthesia staff that works well under pressure and fully understands the special risk factors obese people face on the operating table.

UnitedHealthcare is dedicated to helping those looking towards weight loss surgery.  Various hospitals have responded to a request for information for Centers for Bariatric Surgery and they’ve looked at quality measures such as volume, specialized equipment, expertly trained staff, average length of stay, complication rates and the training of bariatric surgeons.  Based on this information, they’ve made informed recommendations for bariatric hospitals.  If you are considering weight loss surgery and your doctor agrees it’s a good option for you, take the time to research which hospitals are the most trained and how your health insurance will ultimately handle the whole process financially.

California Offers Lessons on Insurance Exchanges

As Congress debates creating insurance "exchanges" as part of a health-care overhaul, the failure of a similar effort in California may offer important insights, former participants in the program say.
From 1993 to 2006, small businesses in California could buy health insurance through an exchange run initially by the government, and later by a nonprofit group.
The plan was undermined when some businesses with relatively healthy workers bought policies more cheaply directly from insurers, bypassing the exchange. That left the exchange with a shrinking pool of less-healthy workers, forcing rates higher and prompting many insurers to withdraw. Managers chose to shut the program in 2006 when one of three remaining insurers withdrew.
"There are definite lessons to be learned," said John Ramey, who as former head of the Managed Risk Medical Insurance Board helped implement California's exchange. "We learned them the hard way out here."
Among those lessons, he and others said: Employers and individuals who qualify must be required to obtain health insurance through the exchange. Failing that, John Grgurina, who ran California's exchange from 2002 until it ended, said government must impose rules governing rates and eligibility to protect the exchange from attracting a disproportionate share of high-risk people.
An exchange aims to get better prices for coverage by banding together businesses and individuals. Insurers would have an incentive to join an exchange because they would gain access to more potential customers. Individuals and employees of businesses that participate in an exchange would be able to chose from the available plans and pay the same rate.
Exchanges, either on a regional basis or a single national one, are likely to be a part of any final health-care legislation. Late Friday, the House Energy and Commerce Committee approved its health-care bill, though a full House vote won't come until the fall.
President Barack Obama on Saturday praised the House committee's action and urged lawmakers to "build upon the historic consensus."
The compromise proposal agreed to in the House Friday exempted more businesses from the mandate to provide coverage to their employees and offered subsidies to fewer individuals to buy insurance through an exchange, which would shrink the number of potential participants.
Each of the three major bills -- one in the House and two in the Senate -- would create one or more exchanges. The specifics vary, but most of the proposals would impose more regulations than the failed California program, which analysts say would help the exchanges compete.
Despite California's struggles, insurance exchanges are still the most effective way to expand coverage, said Elliot Wicks, a health-care consultant who wrote a report on the California program. The report, released last month, was commissioned by the California HealthCare Foundation, a private independent nonprofit.
Veterans of the California effort said the ultimate effectiveness of any exchange would rest on details that have yet to be worked out. They said the pool of people in an exchange should be as broad as possible, to spread both risk and administrative costs.

Coverage at the county level...

Plenty has changed since 2006, the latest year that the uninsured of California was counted by the U.S. Census. But even then, many months before the current recession hit, the percentage of people living without health insurance in our state was startling.
This week, the Sacramento Bee laid out the statistics, finding quite a disparity between those with health insurance and those without. Just in the five-county region The Bee covers, Yolo County posted an uninsured rate of 22 percent of people under 65, while the more prosperous Placer County -- with more employment-based coverage -- posted a 13.7 percent rate.
That's quite a disparity, and the article by Phillip Reese and Anna Tong is worth reading. But the Bee doesn't limit information to its circulation area, it also posts online a comprehensive rundown of each of California's 58 counties' uninsured rate, along with an interactive map of the state and rollover charts.
Here's a sampling of what the authors wrote:

"The uninsured present an immense fiscal and public health challenge: 18,000 Americans die each year because they aren't covered, according to the Institute of Medicine, a nonprofit research organization. This is because having insurance is closely tied to health outcomes: The uninsured won't see a doctor regularly, and if they seek care it is likely to be inadequate or too late.
Moreover, the uninsured are a cost for society: One economist recently estimated the tab at $56 billion per year, 75 percent of which is paid by governments. In cash-strapped California, that cost is critical: 6.6 million residents went uninsured in 2007, more than in any other state, according to the California Healthcare Foundation."
You can bet that, with massive layoffs and small businesses closing since that Census count, the number of those among us -- members of our communities -- who are going without health insurance is a great deal larger. Factor in the Governor and Legislature's cuts in health and insurance programs for lower-income Californians, their children and the elderly, and you get an unimaginable sum of fellow Californians without access to affordable, quality health care -- notably, preventative health care, with better outcomes.
This is what the conversation about health care reform boils down to, not pumped-up talking points and hyper-emotive protests based on misinformation. This is not a partisan issue. It is a people issue. And the bottom line is that the majority of Americans have already voted -- for substantive change for a better future for our country.