Choosing Wisely

A new campaign is hoping to curb unnecessary testing and treatments that drive up costs and increases risk to patients.  Choosing Wisely encourages physicians and patients to do just that…choose wisely.  Each medical organization is choosing five tests or treatments that are commonly ordered but are unnecessary…or even harmful.  The American Academy of Family Physicians has been very involved in the process, partly because Family Medicine has such a broad scope.  (We are also the only organization with two lists…it just didn’t all fit in one.)

During my training, one ongoing theme was to not order a test if it wouldn’t change your care or if it wasn’t indicated.  Seems obvious…but there are many tests out there that are done routinely for no good reason.  It can be hard (as a patient or doctor) to simply say, “We don’t know and we aren’t going to try to find out.”  Not using antibiotics for viruses can be hard for people who are miserable.

I have read through all the lists currently available (over a dozen more are in the works) and feel that they are a valuable read for everyone, whether a physician or a healthcare consumer (aka patient).  You can skip the small print and just read the bold/colored points and use the small print for details on the topics that interest you.  If you have any questions about any of the lists, please ask!

Insurance Prices for 2014 Available

Colorado is one of several states that has published the prices of insurance available in October on the health insurance exchange.  This means you can now guess what to expect.  If you have NO insurance available through work (or the insurance for the employee only costs more than 9% of your total income) you will qualify for a subsidy if you buy your insurance on the exchange.

First: Go to Connect for Health Colorado and calculate your expected subsidy.

Then: Look at this chart on the DORA website to see what a monthly premium would be for a 40 year old (the only information currently available).

If you have kids, see if you qualify for CHP+.  (If you don’t, I have no idea how much insurance will cost through the exchange…less than for a 40 year old, anyway.)

Finally, do your math.

So, let’s say you are a stereotypical family of two children and two parents (both age 40 just because that’s the information we have).  If you gross under $32,500 annually (or a little over $2700 a month, based on this year’s data), you will qualify for Medicaid.  So let’s say you make $40,000 (or $3333 a month).

You calculate your federal subsidy, which comes to $572 monthly if you are only buying insurance for the adults (and putting the children on CHP+) or $938 if you are buying insurance for the whole family.

Your children qualify for CHP+ so you pay the enrollment fee of $35 for two children (it’s $105 for two kids if you make over 200% of the federal poverty level).  The two adults can choose a bronze level plan that starts at $186 per month per person up to a gold or silver plan that costs at least twice that.  To understand the different plan levels, look at page 2 of this link, which shows samples.  For instance, a bronze level plan might have a $5950 deductible.  A gold level plan might have a $640 deductible with a 20% coinsurance once your deductible is met (meaning you pay the first $640 in medical bills and after that your insurance pays 80% of the bill and you pay 20% of the bill until you reach your maximum out of pocket).

Let’s say you choose the gold level plan from Rocky Mountain HMO that costs $412.81 a month for each of the two adults.  You use your federal subsidy and end up spending a total of $253.62 a month on insurance for the parents plus $35 annually for the kids.  You still have to meet a deductible and pay co-insurance for everything that is not preventative but for under $300 a month, you have what most people would consider “good” insurance.

Let’s say instead that you choose the Rocky Mountain HMO bronze level plan for $296.41 per person.  You are now paying $20.82 a month for the parents’ insurance plus $35 annually for the kids.  You know your kids are covered.  The parents’ insurance doesn’t provide much beyond your annual exam until something terrible happens…but once something terrible happens, you don’t risk bankruptcy.  It may take a long time to pay off bills in the thousands, but at least it is possible.  I’ve seen patients have a completely unexpected medical bill leave them with hundreds of thousands or even a couple million dollars in bills.  For twenty bucks a month, that’s pretty good.

If you make more money, you’ll be paying more for the insurance, but everyone making under 400% of the federal poverty level will qualify for some subsidy if they do not have insurance available at work.

What if you do have insurance available at work but you don’t like it?  Or what if it’s cheap to buy insurance for the worker but most of your paycheck to insure the rest of the family?  Anyone can use Connect for Health Colorado to shop for health insurance, you just don’t get a subsidy.  So let’s say you are that same family but Mom has a job that provides her with okay insurance for $300 a month but would cost $2000 a month to insure the family.  Technically this counts as “affordable” according to the laws and so the family does NOT qualify for a federal subsidy (yeah, stupid, but there it is).  This family can still get the kids on CHP+ for the same $35 enrollment fee.  The parents can then look at their options on Connect for Health Colorado and choose anything from the Kaiser bronze plan, which would cost $372.40 a month for both of them up to a ritzy $800-1000 a month option at the higher levels (which would still come out to less than buying a family plan through work).

What does this mean for my patients?  First, according to federal law, everyone in the country will be required to have insurance in January unless you have Medicaid/Medicare/Tricare, a religious exemption (such as a Christian cost sharing plan), or certain other exemptions.  So get some.  Second, if you end up with a high deductible, it still makes sense for most people to keep seeing me…you’re paying out of pocket anyway unless something really terrible happens.  I’ll help keep your bills down in the meantime.  Finally, if you end up with really good insurance and go elsewhere, I won’t get my feelings hurt.  Congratulations on hitting the health insurance jackpot.  I want everyone to be able to have coverage that good but until that happens, I’ll keep doing what I’m doing.

Any questions?  Yeah, we’re all a little confused at this point.  But we’ll work together to figure out the new system.  It’s not perfect, but it’s a huge improvement over what we have right now.  Please contact me if you have any questions.

On Being a Fossil

“The solo practice physician worthy of a Normal Rockwell painting has become a fossil of the past.” Andrew Coates

I don’t know why I was surprised when I saw this in an article about the changes currently taking place within the medical profession.  Increasingly, I am seeing people talk about doctor’s doing “doctor’s work” and having “support staff” do everything else.  What this seems to mean is that doctors are supposed to diagnose and maybe manage the absolute most complicated cases but that everything else should be delegated.  Have diabetes?  A clinician will order your labs and get you your results, a dietician run your diabetes group, a case manager call and harass you if you don’t show up.

I love what I do because I get to do all those things.  I diagnosis, monitor, teach, and harass.  As a family physician, I have the unique opportunity to nag patients who have innocently brought their family members in to my office, not realizing I remember full well that they are overdue for a colonoscopy or are carrying a Big Gulp and supposed to be cutting out simple sugars.  I love that I can change what happens here the moment I decide it needs to be changed.  Schedule inconvenient for people?  Changed.  Seating not comfortable?  Changed.  Need more space for family meetings?  Done.  There is no committee…I just take care of it.

I respect the fact that other physicians are happiest in a group or employed by a hospital.  I’m happiest here.  And I’m NOT a fossil!

Insurance Terminology

Everyone has heard that under the ACA, everyone is required to have insurance.  I do recommend that everyone acquire an insurance plan.  At that same time, I do not for a moment want you to confuse insurance with medical care or the legal definition of “affordable” with a reality definition of affordable.  Many people buying “affordable” insurance will not be able to afford to use it.

All those topics are for another post though.  First, I want to start by reviewing some basic definitions so that as we get into more detail down the road, you will know what I’m talking about.  As you shop for insurance, there are a lot of confusing terms out there that can make it difficult to know what you are looking at.  When I was a kid and first married, it was easy.  The insurance premium was dealt with behind the scenes through your employer and the most you’d see was your portion on your pay stub; at the doctor’s office, you paid a small flat rate copay, often $5 or $10.  Nowadays, you have to sift through a mishmosh of deductibles, coinsurance, copays, premiums, and tax credits.  So what does it all mean?

Premium: This is the amount you pay every month in order to have insurance.  It is similar to (but more expensive than) the premiums you pay for your car insurance, life insurance, or homeowners insurance.  For instance, you might pay $1000 a month for insurance for a family of 4.

Deductible: This is the amount you have to pay for your own medical expenses before your insurance starts paying.  For instance, our car insurance has a $500 deductible.  This means that if we are in a car crash, we have to pay the first $500 of the bill before the car insurance picks up the rest.  With health insurance, the deductible is usually more like $2000 to $4000 before it starts paying.  Under the ACA, insurance policies that are not “grandfathered in” are required to pay for certain limited preventative services without a deductible.  In layman’s terms, your well visit is free.

Co-insurance: This is usually a percentage of the bill you are still responsible for, even after you have met your deductible.  For instance, you might have a 70/30 plan with a $3000 deductible.  What this means is that after you have spent $3000 on your medical care for the year, your insurance will foot 70% of the bill and you are still responsible for 30% of the bill up to a maximum out of pocket expense for the year.

Copays: These are increasingly obsolete.  If you happen to have a “comprehensive” plan, you are paying copays instead of a deductible.  Occasionally with the high deductible plans, you are still charged a “copay” for certain services such as a trip to the emergency room.

Out of pocket maximum: The law dictates that at some point you don’t have to keep paying your percentage co-insurance.  For a family, the legal limit in the small group and individual market  is $12,500 for a year.  So let’s say something totally dreadful happens and you rack up hundreds of thousands of dollars in medical bills and you have a 70/30 plan with a $3000 deductible and a maximum out of pocket (also referred to as a cost sharing limit) of the legal maximum $12,500…you would pay the first $3000 in bills, then 30% of the bills until you’ve doled out a total of $12,500 and then you’re done.  Your insurance will pay 100% your bills for the rest of the year.

HSA (Health savings account): Certain HDHPs (high deductible health plans) can be combined with an HSA; they are designed to work together.  An HSA is a tax-deductible savings account that can only be used for medical expenses.  In 2013, an HSA compatible plan has to have a minimum deductible of $2500 for a family and the maximum contribution to an HSA is $6450 for a family.  Here is a list of medical expenses you may pay for from your HSA.

Tax credit for health insurance (also known as premium subsidies): This is part of the ACA that is supposed to make insurance affordable.  Based on your previous year’s income, the government will pay a certain amount directly to the insurance company to help you buy insurance.  The amount is determined by calculating how much subsidy you would need in order to pay a certain percentage of your income (the exact percentage is determined based on what percent of the federal poverty line you fall at) for a silver level plan (a silver level plan is one that has an actuarial value of 70%…I’m still a little unclear on what that means but just know it’s one plan up from the worst plans that are still legal).  You can then use that subsidy amount towards whatever level of insurance you want.  If you want to spend less on your premiums up front but also get less coverage, you can opt for a bronze level plan.  If you want to have better coverage, you can use the subsidy towards a better plan such as a gold or platinum level plan.  Here’s a brief going into the details.

Cost sharing subsidies: This is an acknowledgement that lower income families and individuals will have trouble paying the higher deductibles and coinsurance associated with the cheaper plans.  This subsidy will help defray those costs.  There is also a lower maximum out of pocket based on income.

Only time will tell if there is any correlation between access to insurance and access to care.  My guess is that while there may be fewer people who are uninsured, there will be many more who are underinsured.  What does underinsured mean?  Come back for the next installment to read about how to determine if you will be able to afford to use the insurance you buy individually or through your workplace.

Summary of Expanded Care in Colorado

C4HCO (1)


Click on the table to see the full summary sheet.  Nearly everyone in the practice will be eligible for one of these programs.  If your workplace starts to offer “affordable” insurance that isn’t actually affordable, you can still use Connect for Health Colorado to find a better plan but will not be eligible for the financial assistance.  Please let me know if you have any questions!

Health Insurance Exchange

We’ve all heard about the Mandate to buy insurance.  We all know that’s starting soon.  But clear information about how this actually works is hard to find.

So how does buying and using insurance work?

  1. Everyone can browse through health insurance options through the Health Insurance Exchange, now called Connect for Health Colorado.  This will be most helpful for small businesses and people who are not able to obtain insurance through their jobs.  The Health Exchange is an improvement over the current method of using a broker because you can easily compare your different options.  The Exchange will also automatically screen you to see if you qualify for Medicaid, CHP+, etc.  Approximately 10% of people who are uninsured (including children) are estimated to be eligible for one of these programs.  Everyone else using the Exchange will have the opportunity to choose from various plans that provide various levels of coverage.
  2. If you are unable to obtain “affordable” insurance (please read below for an explanation of affordable)* through your employer, you will be provided with an up-front subsidy that can be used to buy health insurance through the exchange.  Basically, you’ll log in to the exchange, enter your information, and an automatic payment from the government to the insurance company will cover a certain amount of your premium.  This subsidy is technically a tax credit, decreasing the amount of taxes you owe.**  Use this calculator to play around with this.
  3. Your use your insurance.  See the next installments for an explanation of insurance terms and how this affects how it’s used.

*Unfortunately “affordable” insurance is defined as insurance that costs less than 9.5% of your W-2 income for INDIVIDUAL coverage.  Even if you spend 50% of your income in order to insure your family, this is considered affordable so long as it is still 9.5% or less of your income to insure just the employed individual.  If you are in this situation, you can still shop for insurance on the insurance exchange but you will not be eligible for the tax credit.  Some families will find it more affordable to buy a separate plan for the rest of the family.

**What I can’t figure out about this is that the supposed tax credit can be more than the amount of taxes you actually owe.  For instance, I entered $36,000 into this calculator to determine the expected credit for a sample family of four.  The expected tax credit is $9603.  If you go to this table of tax rates and deductions for 2013 (in other words, the rates that will be used for preparing your taxes a year from now), you will see that this family of four has a standardized deduction of $12,200.  I’m ignoring all the other deductions at the moment to make this simple.  So let’s just say their taxable income is then $23,800 (gross income minus standardized deduction).  Using the tax table, the total tax this family owes $2677 in taxes.  So their tax credit is almost $7000 more than their actual taxes.   I can’t figure out whether any of this is billed to the family.  I would hope not.  (Scroll to the bottom of page 2 of this document from the Department of the Treasury for where I found this information.)  ADDENDUM: I think I found the answer.  The health insurance tax credit is what is referred to as “fully refundable,” which means that it can actually reduce your taxes to below zero and be paid out.  So the only real problem I see with this is that families who have been using their tax refund to pay off debt or invest in a used car will now not receive any refund.


Recently, my husband noticed that Costco was carrying a sunscreen with an amazingly high SPF: 100+.  This seems on the surface to be a great idea.  More protection is better, right?  Unfortunately, sunscreen isn’t all it’s cracked up to be.  I definitely want you to protect yourself from the sun!  But don’t slather on some SPF 100+ sunscreen and then blithely rotisserie yourself in our Colorado sunshine.  What can you do to protect your family?

1. Don’t count on just the sunscreen.  Use other sensible measures, such as staying out of the sun between 10am and 2pm, wearing clothes that provide shade, and wearing sunglasses.  Here are Skin Deep’s Top Tips.

2. Buy safe sunscreen.  Many sunscreens contain numerous questionable ingredients.  Sprays seem easy, but aerosolized chemicals can get into the lungs or eyes.  Here are Skin Deep’s Best and Worstsunscreens for 2012.

3. Be informed.  Remember that manufacturers are out there to make money, not to help you!  Skin Deep’s Surprising Truths About Sunscreen.

So what do I do for my family?  We spend a lot of time in the shade or wear long sleeves and hats, we use one of the products off of Skin Deep’s Top Sunscreens list, and we do regular skin checks to watch for concerning spots.