Insurance Denial and Self-Influenced Health Problems

1. Insurance Denial and Self-Influenced Health Problems

2. A Definition of Health Insurance “A group of persons contributing funds to a common pool, usually held by a third party. These funds are then used to pay for part or all of the costs of a defined set of health services for the members of the pool. This third party can either be a governmental social security, a public insurance fund pool, employer-sponsored pool, or a private insurance fund pool” (Akal & Harvey, 2001, p.18).

3. Insurance denial for self-influenced health problems such as smoking, obesity, heart disease, and diabetes is directly applicable to the nursing profession and society as a whole in. Both positive and negative views of the issue deal with the cost of health insurance and health care, ethics of the insurance system, and individuals taking incentive for their own health.

4. Some Background on Health Insurance

5. High Risk Serious Illness Chronic Illness Self-Influenced Smoking Obesity Drinking/substance abuse

6. Insurance Rates Smokers insurance rates increase ~15.5% over a healthy nonsmoking person of equal age 15 year age increase from 25 to 40 causes ~63.4% increase Data from BlueCross BlueShield

7. Insurance Companies High Risk Protection Exclude preexisting condition from coverage Health Insurance Portability and Accountability Act (HIPAA) limits this to 12 months Uniform Accident and Sickness Policy Provision Law (UPPL) Allows insurers to deny coverage if any alcohol has been consumed

9. Examples of Self Influenced Health Problems Diabetes Cardiovascular Diseases Smoking Alcohol Obesity Related Complications The diseases debated for full insurance coverage are those in which disease expression has multiple components. While having genetic components, these diseases are contracted through environmental factors as well. The main determinant is lifestyle choice, namely diet and exercise. Obesity causes a myriad of diseases and complications. Other lifestyle choices, such as alcohol consumption and cigarette smoking, can have negative health consequences as well. While people have the right to determine how they treat their bodies, as a business insurance doesn’t necessarily have to pay for what amounts to a person’s attempt to shorten their life.The diseases debated for full insurance coverage are those in which disease expression has multiple components. While having genetic components, these diseases are contracted through environmental factors as well. The main determinant is lifestyle choice, namely diet and exercise. Obesity causes a myriad of diseases and complications. Other lifestyle choices, such as alcohol consumption and cigarette smoking, can have negative health consequences as well. While people have the right to determine how they treat their bodies, as a business insurance doesn’t necessarily have to pay for what amounts to a person’s attempt to shorten their life.

10. Lifestyle Complications A Body Mass Index (BMI) of 18- 24.9 is considered ideal Mortality rates rise as BMI’s increase over 25, and at BMI of 30, mortality rates are approx 50% higher (thanks, Patty G.) Diseases associated with obesity: Diabetes, Coronary Artery Disease, Diabetes, Prostate Cancer, Breast Cancer Adult obesity increased from 25% in the 1970’s to 64.5% in 2004 Percentage of overweight children is: 15.5% 12-19 year olds 15.3% 6-11 year olds 10.4% 2-5 year olds America is fat. Trust me, I know. We are culturally inundated with more, more, more. We work longer hours, we eat unhealthy food, and we eat a lot of it. And we are getting fatter. 2/3’s of all adults would be considered overweight/obese. This is a significant increase from the 70’s, when the percentage of people obese was approximately 1.4. People are considered overweight when they have a BMI of 25, and are considered obese with a BMI of 30+. America is fat. Trust me, I know. We are culturally inundated with more, more, more. We work longer hours, we eat unhealthy food, and we eat a lot of it. And we are getting fatter. 2/3’s of all adults would be considered overweight/obese. This is a significant increase from the 70’s, when the percentage of people obese was approximately 1.4. People are considered overweight when they have a BMI of 25, and are considered obese with a BMI of 30+.

11. Diabetes and CAD Diabetes Type 2 Mellitus- 95% of all diagnosed cases. Diabetes cost over 132 million in direct and indirect medical costs. Complications: Renal Disease, Hardening of Arteries, Stroke, Blindness, and Lower Limb Amputations Coronary Artery Disease: In 1999, 571,000 CABG (coronary aretery bypass graft) surgeries were performed at $35,000, costing Americans about $19 billion (Wexler, 2003, p. 56). The less expensive alternative, angioplasty, was performed more than 601,000 times in 1999. This procedure’s cost totaled almost $15 billion in the year 1999 Diabetes is one of the emerging epidemics of the modern era. Because of the mechanics of the disease, the body will eventually fail due to the body’s inability to bring glucose to the body’s cells. The best treatment for Diabetes Type 2 Mellitus is exercise, where the body will consume the extra glucose in the blood. A diet low in glucose, espcially refined carbohydrates like simple carbs and sugar, also minimize the amount of sugar in blood. Other relieving factors are a high fiber diet and consumption of complex carbs, which also regulate the disease. With controls being behavioral, it is difficult to endorse high cost treatments of a disease that has personal control. Coronary Artery disease is another disease in which lifestyle plays an important role. Caused by diet, smoking, and as a complication of diabetes, CAD is the primary cause of death in America. In 1999, it killed 169,000 Americans. And it is expensive to treat as well. In 1999, 571,000 CABG (coronary aretery bypass graft) surgeries were performed at $35,000, costing Americans about $19 billion (Wexler, 2003, p. 56). The less expensive alternative, angioplasty, was performed more than 601,000 times in 1999. This procedure’s cost totaled almost $15 billion in the year 1999.Diabetes is one of the emerging epidemics of the modern era. Because of the mechanics of the disease, the body will eventually fail due to the body’s inability to bring glucose to the body’s cells. The best treatment for Diabetes Type 2 Mellitus is exercise, where the body will consume the extra glucose in the blood. A diet low in glucose, espcially refined carbohydrates like simple carbs and sugar, also minimize the amount of sugar in blood. Other relieving factors are a high fiber diet and consumption of complex carbs, which also regulate the disease. With controls being behavioral, it is difficult to endorse high cost treatments of a disease that has personal control. Coronary Artery disease is another disease in which lifestyle plays an important role. Caused by diet, smoking, and as a complication of diabetes, CAD is the primary cause of death in America. In 1999, it killed 169,000 Americans. And it is expensive to treat as well. In 1999, 571,000 CABG (coronary aretery bypass graft) surgeries were performed at $35,000, costing Americans about $19 billion (Wexler, 2003, p. 56). The less expensive alternative, angioplasty, was performed more than 601,000 times in 1999. This procedure’s cost totaled almost $15 billion in the year 1999.

12. Smoking: The Not So Silent Killer Smoking is the leading cause of preventable death 30% of Coronary Artery Disease-direct correlation with smoking. 28.3% of persons 18-24 and 28% 25-44 smoke. 400,000 Americans die each year from smoking. Known cause of many diseases involving ischemia. Known carcinogenic Ex. Lung cancer Smoking is the leading cause of preventable death. Since it has been made abundantly clear that not only is cigarette smoking is very bad for you, it is a known carcinogenic. The main cancer is of the lung, but many other problems result from smoking as well. from 1995 to 1999, smoking killed over 400,000 people each year… Cigarette smoking is a direct cause of ischemic heart disease, respiratory heart disease, aortic aneurysm, chronic obstructive lung disease, stroke, pneumonia, cirrhosis, and cancer of the liver. Excluding deaths from second hand smoke, males and females lost an average of 31.2 and 14.5 years of life, respectively. Smoking during pregnancy results in an estimated 599 male infant and 408 female infant deaths annually (Huether, 2004, p. 254) While approx 28% of people 18-24 and 25-44 smoke, and that is lower than that of earlier decades, it is also the age group that is most likely to be uninsured. This cohort defers medical treatment until later in life, when smoking for twenty years has filled their lungs and bodies with tumors, resulting in expensive procedures such as MRI, radiation, chemotherapy, surgury, and end of life care.Smoking is the leading cause of preventable death. Since it has been made abundantly clear that not only is cigarette smoking is very bad for you, it is a known carcinogenic. The main cancer is of the lung, but many other problems result from smoking as well. from 1995 to 1999, smoking killed over 400,000 people each year… Cigarette smoking is a direct cause of ischemic heart disease, respiratory heart disease, aortic aneurysm, chronic obstructive lung disease, stroke, pneumonia, cirrhosis, and cancer of the liver. Excluding deaths from second hand smoke, males and females lost an average of 31.2 and 14.5 years of life, respectively. Smoking during pregnancy results in an estimated 599 male infant and 408 female infant deaths annually (Huether, 2004, p. 254) While approx 28% of people 18-24 and 25-44 smoke, and that is lower than that of earlier decades, it is also the age group that is most likely to be uninsured. This cohort defers medical treatment until later in life, when smoking for twenty years has filled their lungs and bodies with tumors, resulting in expensive procedures such as MRI, radiation, chemotherapy, surgury, and end of life care.

13. The Cost of Health Care In 2000, health care costs for the US were 13.1% of our Gross Domestic Product, or $4672 per Capita. The highest of the industrialized countries. Private Insurance pated for 35% of health care costs. Medicare: 17% Medicaid/SCHIP: 16% Out of Pocket: 14% Other Public: 12% Other Private: 5% You!!! Our health system is in crisis. The costs for health care are rising exponentially. In 1980, Healthcare expenditures accounted for 8.7% of the GDP, whereas today it accounts for 13.1%. That is $4672 in health care dollars for every man, woman and child. This is also considering that we have a growing number of people who are uninsured. Out of pocket expenses only accounts for 14% of Healthcare payment, so there is a disconnect between the price of healthcare and what it should be used for. Since there is not a feeling of paying for healthcare, the health care consumer feels that medicine is there to treat whatever problem comes their way, rather than worrying about taking the initiative to worry about their own health. Yes, it is much cheaper to eat healthily than to have to have to undergo dialysis due to kidney failure, but the cost isn’t felt. With drug companies shilling their wares to an uneducated public, the same public has become accustomed to relying on medicine to cure their ails rather than undergoing lifestyle change.Our health system is in crisis. The costs for health care are rising exponentially. In 1980, Healthcare expenditures accounted for 8.7% of the GDP, whereas today it accounts for 13.1%. That is $4672 in health care dollars for every man, woman and child. This is also considering that we have a growing number of people who are uninsured. Out of pocket expenses only accounts for 14% of Healthcare payment, so there is a disconnect between the price of healthcare and what it should be used for. Since there is not a feeling of paying for healthcare, the health care consumer feels that medicine is there to treat whatever problem comes their way, rather than worrying about taking the initiative to worry about their own health. Yes, it is much cheaper to eat healthily than to have to have to undergo dialysis due to kidney failure, but the cost isn’t felt. With drug companies shilling their wares to an uneducated public, the same public has become accustomed to relying on medicine to cure their ails rather than undergoing lifestyle change.

14. Is Healthcare a Privilege or a Right? We felt the true question for the reasoning behind health care denial being acceptable is the question: Is healthcare a privilage or a right? For those who are lucky enough to have coverage through work or wealthy enough to afford private policy, it is a privilage. For the poor and those who are disabled and for the elderly, it is a right, paid for by the government and ultimately the taxpayers. Healthcare costs are probably the biggest problem in healthcare today. Reform is going to be needed on a society wide scale. It will involve not only comprehensive governmental reform, it is going to require a different business model, because this one is crumbling under the pressure of paying for services. That is why promotion and prevention will be the key. This concept is in direct argument with the businesses who make money off of sick people who need their product. That being said, stop-gap measures have to be made until badly needed reform is enacted. One stopgap measure is to limit the treatment of diseases caused by your own actions. This will keep the current paradigm limping along until other solutions can be discovered. Also, a refusal to pay for self-influenced diseases could motivate companies to come up with more promotion and prevention strategies, and make their money in a more healthful and conscionable manner. Finally, realizing that the safety net of free treatment will be gone. The medical field will no longer enable people to be passive members of their healthcare. This could cause people to truly be advocates for their own health. Rather than waiting for healthcare providers to fix their hardened arteries or remove their gangrenous feet, we can assist people in being proactive in their health.We felt the true question for the reasoning behind health care denial being acceptable is the question: Is healthcare a privilage or a right? For those who are lucky enough to have coverage through work or wealthy enough to afford private policy, it is a privilage. For the poor and those who are disabled and for the elderly, it is a right, paid for by the government and ultimately the taxpayers. Healthcare costs are probably the biggest problem in healthcare today. Reform is going to be needed on a society wide scale. It will involve not only comprehensive governmental reform, it is going to require a different business model, because this one is crumbling under the pressure of paying for services. That is why promotion and prevention will be the key. This concept is in direct argument with the businesses who make money off of sick people who need their product. That being said, stop-gap measures have to be made until badly needed reform is enacted. One stopgap measure is to limit the treatment of diseases caused by your own actions. This will keep the current paradigm limping along until other solutions can be discovered. Also, a refusal to pay for self-influenced diseases could motivate companies to come up with more promotion and prevention strategies, and make their money in a more healthful and conscionable manner. Finally, realizing that the safety net of free treatment will be gone. The medical field will no longer enable people to be passive members of their healthcare. This could cause people to truly be advocates for their own health. Rather than waiting for healthcare providers to fix their hardened arteries or remove their gangrenous feet, we can assist people in being proactive in their health.

15. Negative View of Health Insurance Denial Feeling of security when health issues arise Expensive to pay out of pocket Alternative is to forgo medical treatment while health issues worsen

16. Negative view (cont.) Based on the latest data from the continuous National Health and Nutrition Survey, 69.7% of Americans are overweight, obese, or extremely obese (NHANES 1999-2000). Preventing chronic diseases associated with obesity can save the health care system billions of dollars.

17. Negative view (cont.) Health care coverage is necessary for medical attention necessary to attain a healthy weight 5-10% weight loss reduces the risk of obesity-related comorbid conditions (diabetes, heart disease) Achieved through visits with a doctor, Registered Dietitian or drug therapy

18. Negative view (cont.) Moderate weight loss can improve glucose tolerance in the diabetic, lower triglycerides and lipid panel, raise HDL cholesterol and lower LDL cholesterol. Weight loss can improve depression issues and boost self-image

19. Negative view (cont) Individual behaviors and environmental factors account for nearly 70% of all premature deaths in the United States (Edelman, 2006, p. 232). Vital that individuals who want or need medical interventions in order to change their lifestyle habits have access to health care

20. Solutions for Insurance Coverage for Self-Influenced Health Problems

21. Two-Tiered Health Care System Used by most developed countries Public and Private Sectors Increased Premiums for those with declined health Guarantees Public health care, but also has a private sector only available for those who can afford it Premiums are the rates that people pay for their insurance coverage They are based on certain health risk factors along with other factors such as ageGuarantees Public health care, but also has a private sector only available for those who can afford it Premiums are the rates that people pay for their insurance coverage They are based on certain health risk factors along with other factors such as age

22. WA’s Other Insurance Option Insurance denial pending one’s results of their risk factor score is not the last option. Washington State Health Insurance Pool currently offers assistance to Washington residents who have been denied coverage. Goals of WSHIP: reduce barriers, improve the affordability to the enrollee and member plans, promote innovative care delivery, balance costs and benefits, and identify and implement key quality measurements Goals of WSHIP: reduce barriers, improve the affordability to the enrollee and member plans, promote innovative care delivery, balance costs and benefits, and identify and implement key quality measurements

23. Universal Health Care Canada currently operates under a plan providing health care to all residents of Canada. The public is ensured reasonable access to all medically necessary hospital and physician services. Through their plan or version of Medicare, no one is denied health care benefits or coverage. Through their plan or version of Medicare, no one is denied health care benefits or coverage.

24. Satisfaction of the Health Care System United States vs. Canada US residents are one third less likely to have a regular medical doctor one forth more likely to have unmet health care needs and more than twice as likely to forgo needed medicines One of the negative consequences of Canada’s health care system is that there is usually a long wait time before you can have medical treatment due to the higher number of people that health care. One of the negative consequences of Canada’s health care system is that there is usually a long wait time before you can have medical treatment due to the higher number of people that health care.

25. Health Care System Reforms Must focus on health promotion Lower health care costs will directly affect health insurance costs Decrease in health insurance costs allows more people to be covered Domino Effect? lower health care costs= lowered health insurance costs, which in turn lowers the amount of people that get deniedDomino Effect? lower health care costs= lowered health insurance costs, which in turn lowers the amount of people that get denied

26. Nursing Application Our role: Advocate for patients Educator Health Promotion Ethics Code of Ethics- established by the American Nurse Association ?As an advocate, “the nurse helps individuals obtain what they are entitled to receive from the health care system, tries to make the system more responsive to client and community needs, and assists client in developing skills to advocate for themselves” Edelman Makes sure the client is receiving adequate health care even if they don’t have health insurance Educate them on how to make healthier choices or lifestyle changes ? Code of Ethics emphasizes our role as a health promoter and educator ?Through all of these, nurses work to minimize/reduce self-induced health problems through health promotion. ?As an advocate, “the nurse helps individuals obtain what they are entitled to receive from the health care system, tries to make the system more responsive to client and community needs, and assists client in developing skills to advocate for themselves” Edelman Makes sure the client is receiving adequate health care even if they don’t have health insurance Educate them on how to make healthier choices or lifestyle changes ? Code of Ethics emphasizes our role as a health promoter and educator ?Through all of these, nurses work to minimize/reduce self-induced health problems through health promotion.

27. Nursing Application Reimbursement Facilities that nurses work for are reimbursed for providing patient care by insurance companies Limited quality level of care Decreased funding reflects the quality and level of care provided by nurses Reimbursement directly affects nurses and their quality of care If funds are reduced due to lack of reimbursement, nurses are subjected to enforcing lower standards of careReimbursement directly affects nurses and their quality of care If funds are reduced due to lack of reimbursement, nurses are subjected to enforcing lower standards of care

28. Summary of Pros and Cons Positive view of Insurance Denial: Lower health insurance and health care costs. More affordable for those who currently can’t afford it. Motivates individuals to be accountable for their own health and well-being. Negative view of Insurance Denial: It is the right of the individuals to receive health insurance and health care. Not covering high risk individuals could ultimately result in a higher cost for the public. Unethical to discriminate based on lifestyle choices.

29. Has Your Opinion Changed?

30. Group Perspective As a group we feel that it is wrong to completely deny insurance coverage for individuals based on their high risk behaviors. However, high risk individuals should be required to pay a higher premium, or be denied coverage for specific health care procedures pertaining to their self-influenced health problem.