One of my favorite non-health care policy organizations, the Drug Policy Alliance, has a flash animation out about an insurance company that fired four smokers for possibly smoking in their free time. The company allegedly believes that it’s OK to fire smokers because their health care costs are likely to be higher than other peoples.  The Drug Policy Alliance folks’ sub-text is of course that what you do in the privacy of your own home away from the workplace is your business and not anyone else’s including your employer, so long as you do a good job in your workplace, and by that they mainly mean pot-smoking.  There was also a great study a while back that showed historically that companies that drug-test their employees do worse in terms of standard business measures like productivity and stock performance than those which don’t.  And of course no one is yet alcohol-testing employees, unless it concerns taking alcohol immediately before flying a plane or something similar which impairs the ability to do a good job.

But the key points in this "firing smokers" issue were drawn home to me while watching a Harris Interactive webinar yesterday. (The webinar will likely be up here sometime soon but doesn’t seem to be up yet.) They’ve done a lot of work about the obesity problem, and as their colleague Bill Rosenberg said it’s getting clearer that there’s little point in a company trying to do anything to reduce the obesity in its workforce  — there’s no ROI there.  So the next best option to reduce health care costs is of course to get rid of those who cost the most.  Once we’ve got rid of the smokers, drinkers, druggies and perverts, then who’s next?  The obvious answer is that it’s the fat and the sick, who of course tend to be lower paid than average, which in turn means that their health care costs are a higher proportion of their overall compensation.

I also had a recent meeting with Brian Klepper and Patricia Salber of the Center for Practical Health Reform.  They believe that employers are dropping out of offering benefits rather more rapidly than the overall figures suggest, and Brian points to a study showing that only 45% of jobs come with health insurance (as opposed to 62% of people getting their health insurance via someone’s insurance), and that the percentage of jobs offering insurance is going down by up to 5% a year. And of course the amount of coverage being offered in the brave new high-deductible world is at least somewhat (and maybe greatly) less than people were used to a few years ago. They believe that this is leading to a crisis of funding for the whole system, and have some interesting ideas about what to do.

But in the absence of reform (which will last at least another 4 years) there’s a very nasty scenario in all of this.  Employers may actively start looking at their workforce with an idea of who to keep in and who to kick out, based purely on their health status.  After all insurers have done this for years, to great effect on their bottom lines.  Now that many big employers really see health care as their biggest challenge, and small employers get the picture too, what’s to stop them really looking at the pre-cursors for health care costs and getting rid of people who smoke, look fat, or like a drink, or are getting old?  Nothing really, especially as a class-action lawyer won’t take on a small company because they haven’t enough money to be worth taking down. Particularly for a small employer, they don’t have to state anything in their policies about it, or even look into medical records, as those things are pretty self-evident.

And of course the costs of this end up on the individual and the taxpayer.

An internal review at the National Institutes of Health has
cleared many of the NIH researchers the agency had earlier accused of violating
conflict of interest rules, the Washington Post reports.
NIH director Elias Zerhouni asked for sweeping restrictions on outside
consulting after reports of widespread rule breaking. The Post notes:

"The finding that most of the allegations are false has
many scientists complaining that Zerhouri did not get a better measure of the
the problem before succumbing to pressure from congress and the government
ethics office to prohibit virtually every kind of outside collaboration and to
demand across the board divestitures."

The Los Angeles Times played a major role in bringing the consulting crisis to
a head with a series of front page stories
in December focused on prominent scientists at the NIH including cholesterol
researcher Dr. Bryan Brewer, a member of the team which developed the nation’s
new cholesterol guidelines two years ago and Dr. Harvey Klein, a leading expert
on blood transfusions.

Interestingly, the adversarial relationship between the paper and the NIH dates
back to at least to the late nineties, as this 2003 piece by Slate’s Jack Schafer
documents.

The Post has an editorial
today which agrees that changes were necessary  but argues the
proposed restrictions on consulting and stock ownership are far too
harsh.  As the paper notes, the findings of the internal review appear to
support the position that Zerhouni may
have seriously over reacted.  Of course, it remains to be seen if anybody
will be convinced by  an internal review.

There’s been quite a fuss about the recent study showing that bankruptcy is frequently caused by high health care bills, or at least by the inability of those who are sick to return to work and pay off those bills. THCB contributor Anonymous wrote about her tough experience accessing care last November.  Now the bills are due and she finds herself on just that slippery slope. Here’s Anonymous story:

I was seen at the Alta Bates ER twice within a week for the same problem. Both times I received a form for the charity program. No one explained anything to me about two separate billing systems or that the charity program wouldn’t apply to the physician part of the bill. I initially needed help providing the proof required by the charity program. Alta Bates ignored my first letter in this regard, and I went through phone tree, transfer, and wait time hell to get to the right department to help me with the problem. When I eventually ended up with a financial counsellor, who was very helpful. She told me she could use  my prior year bank statements, and the charity care program then covered me 100%. I thought everything was wrapped up at that point.
A couple months later, I started receiving threat letters and calls from a collections agency. I called the financial counsellor and asked why I was being billed after I had been covered by the charity care program. She told me that there was a separate physician’s bill not covered by the charity care program. She also told me I had another outstanding bill from 2001(!) The 2001 bill is from a time when I was covered by insurance: I didn’t find out about that until it went into collections, either. But at that point I called my insurer, Blue Cross, and they took care of it. I haven’t heard about it since. Now Alta Bates expects me to remember my insurance information from 2001 to fix it when they were the ones who made the mistake of only applying my insurance information to one of my bills. I’m just boggled by that. Anyway, the counselor told me she couldn’t help me further at that point, and she gave me no guidance on how to proceed.
I went through phone tree, transfer, and wait time hell again, and I ended up at Berkeley Medical Group. I explained to them that I had qualified for the charity care program, no one had explained the two-bill concept or provided me with any alternate charity forms in the ER, and that I had been unaware that I had an outstanding bill until it had gone into collections. I was given the address of somebody in Washington State to write if I want to dispute the bad debt from 2001.The Berkeley Medical Group representative told me that they have no charity program and the fine print of the third bill warns it would go into collections. She did not seem to get what was wrong with the fact no one in the ER explains the fact there are two separate billing systems or explains steps indigent patients should take beyond giving them the forms for the charity care program. I asked her how I should proceed. She told me I had to deal with the collections agency now, and there was nothing she could do for me. I pointed out that the only thing adding a bad debt to the credit record of a person with no income would do would be to make it even harder for them to recover financially and be insured and/or able to pay such bills in the future. She told me that all I could do was call the collections agency.So, here’s where things stand now. I’m not going to call the collections agency. I went through this with the same agency in 2001 to deal with Alta Bates’ billing mistake, and I know this particular agency, American Capital, has a bad business reputation. I will only be setting myself up for threats and harassment if I call them. One amusing aspect is that the collections agency has been leaving messages on my answering machine: they don’t say who they are, but they give the collections case number and expect me to call them long distance! Anyway, I’m not going to deal with them.
I’m considering filing for bankruptcy. Whether I do that depends on whether I can take care of my student loans at the same time. My student loans might be exempt from a bankruptcy claim because they can always be deferred, but if I can get the loans taken care of that means that bankruptcy for hospital bills has larger ramifications for the U.S. financial system as a whole. I’m sure anyone who has to file bankruptcy for a hospital bill will take care of their other bills while they are at it. The question for me at this point is whether it does more damage to my credit rating to file for bankruptcy or simply ignore the collections agency notices. Which will fall off my credit record faster?  I’m also amazed that Alta Bates has been continuing a practice that’s bound to confuse anyone who comes to their ER. Because of the 2001 billing problem, I know that problems like this have been going on at least that long. Surely I’m not the only person who has brought up that patients aren’t being given all the information in the ER. I’m wondering if there isn’t a Patient’s Bill of Rights violation in there somewhere. Even if there isn’t, Alta Bates and Berkeley Medical  Group end up paying extra administrative costs to hunt down people who were simply confused by their billing system.

This type of foul up is very common.  A friend of mine who was well insured was sent to collections by a local medical center for a bill he’d already paid and was dismayed to find it reported as an unpaid debt recently on his credit report when he wanted to get a mortgage. And I personally just finished getting an unnamed insurance company to pay my final provider bill because they had miscalculated my deductible for surgery I had back last April. The move to more HSAs and forcing more people into dealing with a system that can produce bills from 5-10 seperate providers from one procedure is not exactly going to simplify matters. Horror stories like that of Anonymous’ are going to multiply.