Wednesday, November 26, 2008

What Tennessee Is Doing About Health Insurance: Coverage with limits is better than no coverage at all

By Phil Bredesen, Democrat governor of Tennessee. He seems to have unusual realism for a Democrat

Three years ago, I realized something about health care. I've taken part in uncounted policy discussions about America's uninsured, both as governor of Tennessee since 2003 and before that as CEO of Nashville-based HealthAmerica Corp. Everyone regularly criticizes the unfairness of the system. But we don't make progress.

What I realized was this: Everyone proposing solutions or criticizing unfairness was doing so from the comfortable vantage point of having good health insurance. While we work to build a better system, wouldn't it also be responsible to find a way to get something -- not a perfect solution, not even a long-term solution -- into the hands of the more than 46 million uninsured Americans who don't share our good fortune?

Dottie Landry is one of those uninsured Americans. She lives in Nashville and is self-employed. She makes and sells jewelry. Over the years, she has been generally healthy but uninsured. In 2000 she got very sick -- from a tick bite -- and had to spend about $9,000 for medical care. She put most of it on her credit cards, which took years to pay off.

We all want to help Ms. Landry, but here's the problem: a comprehensive health-insurance policy for her costs about $5,000 a year, and someone has to pay that. That's a real number that won't go away with group purchasing or by beating up insurance companies. Ms. Landry can't afford that, and in a world of trillion-dollar deficits it's hard to see how the federal government can either.

We need a national health-insurance solution, but isn't it sensible in the meantime to make sure everyone has a basic health plan before we give a few more people a perfect but expensive one? Shouldn't we make sure everyone at least has a Chevy rather than providing a Cadillac to a few and letting the rest walk? We're trying that in Tennessee with CoverTN.

CoverTN, which began in 2006, is a health-insurance plan for those who are self-employed, or who work for small businesses that can't afford a traditional policy.

It is not free health care. Rather it is a limited plan with shared costs. In devising this plan, we didn't start out the usual way -- by defining what benefits we wanted -- but instead set how much we wanted to pay. And then we began a competitive-bidding process to see how much health care we could buy. We initially set the amount we would pay at an average of $150 a month, and split the responsibility for that premium three ways. The company would be responsible for $50, the individual for $50, and the state for the final $50.

The bidding was vigorous. It was ultimately won by BlueCross BlueShield of Tennessee with a benefit package that meets a great many -- not all -- of the real needs of the uninsured at a cost far below conventional plans.

At these premium levels -- less than half of what a conventional plan might cost -- the benefits are limited. But the benefit structure is also different than in a conventional plan. Most limited plans achieve their savings with high front-end deductibles, requiring a person to spend often thousands of dollars out-of-pocket before benefits kick in. But when we asked our customers -- uninsured Tennesseans -- what they actually wanted, we found that they were most interested in some help with the more common things; a doctor's visit, prescriptions, a short hospital stay.

CoverTN emphasizes covering these front-end costs. It features free checkups, free mammograms and $15 doctor visits without deductibles, for example. And it achieves its savings on the back end, with relatively low limits on hospital stays and an overall $25,000 benefit limit in any one year. It does not cover truly catastrophic events. This makes medical sense. Good access to a doctor and a drugstore when you first have a problem can avoid a lot of cost and heartache later.

One thing that has been unexpected is the success of a generics-only prescription drug program. We needed to cover medications, but because of the high prices and aggressive marketing of branded prescription drugs, we were concerned that the costs would overwhelm the program. With some misgivings, we required our bidders to propose a largely generic prescription program. It's worked surprisingly well. Physicians have typically been able to select suitable medications for their patients, and patient satisfaction has been high and complaints few.

Having been badly burned by uncontrolled growth in costs in Tennessee's Medicaid program (TennCare once gobbled up a third of the state's budget), we proceeded cautiously with CoverTN and have been rewarded with good control of costs. This fall we added some benefits: The number of primary care visits doubled from six to 12, for example. Best of all, we added them without increasing rates. When did you last hear of a health-insurance plan whose annual update was a benefit improvement but no rate increase?

An obvious and valid criticism of health insurance such as this is what happens when a patient exceeds the benefit limits. What we're finding is that even in health care, when people know that there are limits, they work to manage their costs. This year, as of the first nine months, only four people out of the more than 15,000 people covered had hit the maximum overall limit of $25,000, and only three had exceeded the separate in-patient hospital limits. A larger number, under 4%, hit the quarterly pharmacy limits during those first nine months. Even those who go over the benefit limits get the significant advantage of being able to piggyback their personal expenditures on the contracts CoverTN has negotiated. By doing this, they often can cut their costs on uncovered health care in half.

Ms. Landry, to continue her story, has joined CoverTN and is very happy with it. About a year and a half ago, right after she joined, she had a bad dog bite that put her in the emergency room with several follow-up visits. The cost for this episode was about $4,000, and CoverTN paid for almost all of it.

The Chevy plans certainly have their critics, and I don't offer CoverTN as the perfect or ultimate answer, but it sure has worked for Ms. Landry and thousands of other Tennesseans.


Britain: A volunteer testing a new treatment died after doctors `missed' a side effect

No vigilance for known serious side-effects

A young widow has revealed that her husband died in a government-funded drug trial - the second victim to be identified. Gareth Kingdon, 39, who was father of a seven-month-old boy, was poisoned by one of the drugs being tested as a new treatment for testicular cancer. His widow Victoria, also 39, from Tunbridge Wells, Kent, said this weekend that he might still be alive if doctors had withdrawn the medication, bleomycin, when signs of side effects first emerged.

She argued that doctors at the Royal Marsden hospital, London, should have noticed signs of lung damage and stopped the drugs. He developed a persistent dry cough, a sign of damage caused by bleomycin, yet they continued to administer the drug for about another month. He was transferred to a critical care unit shortly after the last dose in November 2006.

Two months ago The Sunday Times reported that Gary Foster, 27, had died after he was given an overdose of bleomycin at University College London hospital (UCLH) in 2007. The publicly funded Medical Research Council, which is running the trial at several hospitals across Britain, has admitted that two other men were given overdoses. After Foster's death the trial was suspended at UCLH - where there had been a computer error in setting up the dosage control. The revelation that another patient had died a year earlier raises questions about whether it should be continued at other hospitals.

The deaths also raise broader safety concerns two years after the "elephant man" case, which was supposed to have led to tighter supervision. Six men nearly died when their bodies swelled horrifically after taking an experimental drug in trials conducted on the site of Northwick Park hospital, London, by Parexel, the testing company. All the men suffered multiple organ failure.

Kingdon, who was a senior tax executive at the Ford motor company, was diagnosed with testicular cancer in the summer of 2006. His family were given documents that put the normal survival rate at 50%. They say doctors told them that his chance of beating the cancer if he took part in the trial of a new treatment was about 90%. The trial, TE23, is testing whether a combination of five existing chemotherapy drugs, including bleomycin, is better at treating testicular cancer than the standard treatment of three drugs.

Victoria Kingdon, a former marketing manager, said her husband joined the trial in August 2006 and developed a cough two months' later: "Gareth was showing signs of toxicity from the bleomycin. He had a dry persistent cough from early October. I even have the cough medicine he was prescribed. "The last cycle of chemotherapy was early to mid-November 2006. They should have stopped his entire last cycle. If they had done that, Gareth may very well have been with us today."

She added: "Gareth was so sick, I said to him, `How can they think you are well enough to have chemotherapy today?' but they went ahead with the last round," she said. "Gareth went into the critical care unit shortly after the last dose was administered."

The couple's son, Gus, was seven months old when Gareth Kingdon died. Victoria Kingdon was fighting breast cancer at the time, which, she said, had hindered her ability to seek justice for her husband. After having a mastectomy she is clear of the disease and is seeking legal advice.

Kingdon acknowledges that bleomycin is an effective drug if monitored closely. Between 1%-2% of patients taking bleomycin die of the damage it causes to their lungs.The Medical Research Council has declined to disclose how many of the 59 patients in the TE23 trial have died from toxicity caused by bleomycin.

Kingdon said: "We were, like the Foster family, delighted that Gareth got invited to participate in the trial. There is a contract of trust between patient and doctor, however, and where I think mistakes may have been made is in the vigilance to look for symptoms like the dry cough that both Gary Foster and Gareth suffered and to act on them quickly."

Mark Bowman, a solicitor with the law firm Field Fisher Waterhouse, who had acted for Foster, said: "As soon as someone develops toxicity, doctors should stop giving bleomycin. That appears not to have happened, which is of concern."

The Royal Marsden NHS Foundation Trust said: "We would like to again pass on our sincere apologies to Mr Kingdon's family for their sad loss." It declined to comment on the cause of his death. The Medical Research Council has reviewed its trial procedures and introduced additional checks since the deaths. It pointed out that deaths from cancer drug toxicity are an acknowledged hazard. It added that the trial had been monitored by an independent committee and that it would be stopped early if there were concerns about a higher number of deaths than had been expected.


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