Health or Sickness (6/19/2007)

Why don’t more health insurance policies emphasize wellness instead of sickness?  Tommy Thompson, former U.S. Secretary of Health and Human Services, said (quote): “We spend $2 trillion on health care.  That’s 16 percent of the gross national product.  93 percent of the cost of health care goes into waiting until after you become sick.  Only 7 percent of the money is used to keep you well in the first place.”  (end quote)

The State of Illinois offers its employees and retirees the Quality Care Health Plan, administered by Cigna.  Unfortunately, this plan limits wellness services and focuses more on sickness than on health.  Its gaps in preventive care can result in high costs for illness that could be prevented.

For example, the plan doesn’t cover inoculations such as those for typhoid and hepatitis, which are recommended for travelers by the Centers for Disease Control, even though the care for these illnesses may costs thousands of dollars and great suffering.  And medical care is only one facet of the cost to the state.  The state is likely to pay for sick time for the employee who misses work, possibly for disability, and even for a substitute worker.  Wouldn’t it be more cost effective and compassionate to encourage and pay for inoculations?

Some other plan rules are equally inane.  A senior told me she was denied coverage for a cholesterol test because her previous year’s test showed her level was fine.   So does this mean she has to suffer a stroke or some other health crisis before another cholesterol test is approved?  Wouldn’t it make more sense to pay for an annual check to avoid serious problems? 

Even the routine yearly physical exam limits coverage in a peculiar way.  My exam included an EKG and, since I’m pre-diabetic, a urine analysis.  Because the combined exam, EKG and urine analysis cost more than the amount allowed for a physical, I bore the cost difference.  Cigna told me that if I had scheduled the tests apart from the physical exam, the insurance would have paid for them.  In other words, make another appointment with the doctor on a different day so the tests’ costs are billed separately from the physical’s cost.  Two appointments would cost the insurance more, not to mention taking up more of the doctor’s costly time and my time. Who develops, and on what basis, these insurance policy decisions?

I wrote to the Illinois Deputy Director, Bureau of Benefits, Central Management Services, which oversees Illinois’ health insurance plans, and asked how the decisions are made.  I suggested that better preventive care would be more compassionate and cost effective, and requested information about how the health benefit structure is reviewed, who’s involved, when the reviewers meet, and how individual citizens might participate. The Deputy Director replied that the review is (quote) “less structured than your questions would presume, although formal meetings may well develop.”  (end quote)  She asked for my recommendations.  So I again sent them and asked for copies of the minutes of the review meetings.  This time, the response came from a Freedom of Information Act officer that the information I seek is exempt from disclosure. 

The Deputy Director had said in one of her letters, “the State must balance the needs of the consumer with the public fiscal responsibility.”   So I was puzzled. Why is the current Quality Health Care plan unbalanced in terms of consumer needs and sound fiscal policy, when both could be greatly improved?  And why are my attempts to gain information being stonewalled?  Surely our state wants healthier citizens and wants to save money.  I’ve appealed the denial.  Stay tuned.

- Judith Kohler

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