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Health insurance on the front lines of emerging diseases
"A hot virus from the rain forest lives within a 24-hour plane flight from every city on earth," Richard Preston wrote in his book The Hot Zone.
Above, a virus
Today, viruses, killer bacteria and an alarming assortment of lethal creepy-crawlers are just as likely to arrive on your dinner plate at a restaurant, or be lurking in your swimming pool, as they are to arrive by plane.
Health insurers make a plan
Health insurance companies have been training for outbreaks, much like first responders train for natural disasters and terrorist attacks.
In January 2008, America’s Health Insurance Plans (AHIP), an industry trade group, conducted a two-day pandemic simulation and then released a report outlining what should be done if a pandemic influenza outbreak gripped the United States. The "trial-run" practiced how insurers, health care providers, government officials and representatives from large industries like transportation and telecommunications would handle emergency medical care in the face of a catastrophic pandemic.
Six groups representing different organizations, disciplines and constituencies had to address a pandemic that would last approximately 12 weeks, giving the participants the opportunity to "live through" a full-pandemic cycle. They were presented with a new pandemic that was rapidly crossing the globe and had to invent strategies for managing the care of those afflicted.
The scenario went like this: In less than one month, the number of new infection cases begins to escalate into the thousands across Asia and Europe. Then it starts to appear in California, New York and Pennsylvania. The government issues a directive telling people to avoid public gatherings. Hospitals are overwhelmed with the sick, businesses report high absentee rates, and schools across the country send students home. Transportation hubs are in total disarray as people flock to the airports, subway stations and highways to get to areas of the country that are still considered safe. International and domestic shipments are slowed or cease operations entirely, ending delivery of much-needed supplies. Life and health insurers face a spike in claims and requests for immediate payouts.
Participants in the simulation recommended:
- Finding ways to facilitate cash flow to health care providers and initiate a more efficient claims-payment system, with emphasis on hospital payments, to ensure delivery of care without disruption.
- Remaining in constant contact with employers to determine the state of their financial stability, including their ability to continue to pay health insurance premiums
- Simplifying insurance plans to ensure coverage.
- Providing pre-pandemic coverage for those who lose their employer-sponsored health plans if companies go out of business or have massive job losses.
- Halting surgery or treatment that is not emergency-related in order to divert all medical personnel and claims payments to pandemic patients.
"Insurance and health care providers would not postpone emergency treatment or urgent care per se, but when you have the potential for hundreds of thousands of people who could die from a particular infection, we want to be sure we remain focused on the priority," says Susan Pisano, spokesperson for AHIP.
Pisano explains that elective surgeries such as a knee replacements and treatments that are not a matter of life and death would be postponed in order to redirect care to those hit by the pandemic.
"If it’s a true pandemic, it would not be contained in one area," says Pisano. "It would be moving so rapidly that no one would be unaffected."
There is a lengthy list of "emerging diseases" that are only beginning to wend their way through the human population. Is your health insurance plan ready to tackle treatments for diseases that are making their first appearances?
Trust for America’s Health, a nonprofit disease-prevention group, estimates that 170,000 Americans die each year from new or re-emerging infectious diseases. The causes of an infectious disease vary, but according to the Centers for Disease Control (CDC), the overuse of antibiotics, global trade, travel and migration, breakdowns in public-health measures and even extreme weather can fuel outbreaks.
Attention is focused now on swint flu, and in the past include West Nile virus, the Avian flu, Ebola and SARS have captured Americans' attention. There are plenty of others that pay unwelcome visits to the U.S.
Swine flu: Influenza H1N1
This flu strain has gripped Mexico. In the U.S., confirmed cases have been identified in Arizona, California, Illnois, Indiana, Kansas, Maine, Massachusetts, Michigan, Nevada, Ohio, New York and Texas.
According to the CDC, this respiratory disease is typical in pigs but person-to-person transmission has occurred in this outbreak.
Symptoms of H1N1 are much like any other flu: coughing, body aches, sore throat, headache, chills and fatigue.
"Insurers have put a lot of work over the last five to 10 years nationally, in all sectors — including government and the private sector — to prepare for the possibility of a pandemic outbreak. A lot of work has gone into emergency planning and we are in a better place to handle this situation today than we were a decade ago," says Pisano.
"Insurers are invoking pandemic plans right now, but it hasn't been declared. Until it is declared, insurers are following steps recommended by public health authorities," she says.
Pisano says some insurers are giving guidance to their members about preventive measures such as social distancing and infection control.
Cheryl Randolph, a spokesperson for UnitedHealthcare, says the company's management team has held multiple meetings over the last several days to assess outbreak concerns.
"We are making sure our operations and community-continuity plans are updated in real time to coincide and share any new information coming in from the CDC and local and state health agencies regarding swine flu," she says. "We are continuing to examine existing HR policies concerning sick leave to determine if any changes should be considered at this and future stages. Our technology and remote infrastructure capacity has been reevaluated in the event there may be a need for off-site employees to help with the claims process. And, in addition, we are manning our nurse line and crisis helpline so we can offer advice to members who have questions and concerns about the outbreak."
Aetna, Blue Cross Blue Shield, Highmark and others are ready to implement pandemic plans if necessary.
H1N1 claimed its first U.S. death in Texas on April 29, 2009.
The World Health Organization (WHO) reports that H1N1 has reached Phase 5 of its worldwide pandemic alert. When a virus reaches Phase 5 it is characterized by human-to-human spread of the virus into at least two countries. The declaration of Phase 5 indicates that a pandemic is imminent. Phase 6 is characterized by community-level outbreaks in at least one other country in a different region of the world in addition to the criteria defined in Phase 5. Phase 6 indicates a global pandemic is under way.
Brain worms: Neurocysticercosis
Remember that bacon you enjoyed the other day? When pigs are kept in unsanitary conditions and eat human feces, and then you eat a pork product that wasn’t cooked properly, a nasty little worm can take up residence in your digestive track and make its way through your bloodstream — eventually traveling to your brain.
If a tapeworm remains in your system undetected, it may result in lesions on the brain, or a condition called neurocysticercosis.
Brain worms can be contracted from unsanitary food-handling practices — such as a restaurant kitchen worker who serves food that was tainted with the feces of a person infected with a tapeworm parasite.
The condition is ultimately detected through MRIs and CT brain scans.
Symptoms include seizures, headaches, confusion, balance problems and swelling of the brain. Death can occur suddenly with advanced infections.
Multidrug resistant tuberculosis and extensively-drug resistant tuberculosis
The re-emergence of this old foe in the hierarchy of infectious diseases means that tuberculosis (TB) continues to be a bane of human existence.
The simple act of sneezing, coughing or talking can spread TB from person to person.
The emergence of a "multidrug-resistant tuberculosis" (MDR-TB) followed the onset of the HIV/AIDs virus. This form of TB is resistant to the anti-TB drugs isoniazid and rifampicin. It is acquired during the course of treatment (or rather mistreatment) for TB. Skipped medicine doses, inappropriate treatment by doctors, and patients who fail to complete their treatments create this aggressive form of TB. When an outbreak occurs, it affects patients with severely compromised immune systems.
Multidrug-resistant TB is vexing to health officials because the strain has developed resistance to the first- and second-line antibiotics used to treat it. Regions hardest hit by MDR-TB include China, Eastern Europe, the former Soviet Union, India and Southeast Asia.
The next wave is "extensively-drug resistant tuberculosis" (EDR-TB), which follows medical mismanagement of MDR-TB. It is resistant to at least four common TB drugs.
Dr. Peter Cegielski, team leader for the drug-resistant TB branch of the CDC, says the driving force worldwide is that effective drugs are not available in most countries. "The cost of care for MDR-TB and EDR-TB is 100-fold more expensive than treating standard tuberculosis," he says.
Cases of TB are increasing worldwide. In the United States, cases are not decreasing as fast as they used to, says Cegielski. This leveling off worries health officials.
Cegielski says that anyone immigrating to the U.S. is screened for TB before they are allowed to enter the country.
Symptoms of TB are a bad cough lasting three weeks or longer, chest pain, coughing up blood and phlegm, chills, weight loss, night sweats, fatigue and fever. Chest X-rays and a skin test determine the cause.
Brain-eating amoeba: Naegleria fowleri
The next time you take a dip in a lake or a friend’s heated pool, you may expose yourself to this creature.
This rare organism is found in warm freshwater lakes and hot springs and could infect you with a potentially fatal disease called amebic meningoencephalitis, or Primary Amoebic Meningoencephalitis (PAM).
After traveling up your nose, the amoebas, called naegleria fowleri, set up camp in your brain tissue and gorge themselves. As you and your immune system remain oblivious to this chow down, you develop a severe and a fatal brain infection.
PAM starts one to 14 days after infection. Symptoms include headache, fever, nausea, vomiting and a stiff neck. Later-stage symptoms include confusion, loss of balance, seizures and hallucinations. The disease progresses rapidly and causes death in three to seven days. A CT brain scan and lumbar puncture can detect it — if you get medical help on time. A drug cocktail of steroids, antifungal medications and antibiotics are sometimes effective if caught early. To date, there have only been eight survivors of this disease worldwide.
Skin lesions from sand flies: Leishmaniasis (kala-azar)
In places sandy and hot, certain species of sand flies are causing chaos among campers, vacationers and soldiers.
A bite from an infected fly can cause a parasitic disease that leaves large lesions and scars on the skin. Other results are fever, anemia and swelling of the liver and spleen. Some strains are fatal.
The most recent cases have been reported in Texas and Oklahoma. U.S. soldiers returning from Iraq are banned by federal officials from giving blood for up to a year as a result of rampant leishmaniasis infections among soldiers serving in the Persian Gulf and Afghanistan.
Strep throat x 100: Streptococcus pyogenes
The bacterium behind strep throat has branched out, causing two highly aggressive infections: Necrotizing fasciitis (flesh-eating bacteria) and MRSA.
Necrotizing fasciitis destroys tissues underneath the skin, most commonly on the arms and the legs. This extremely painful skin infection can create dangerously low blood pressure that leads to heart, liver and kidney failure. It thrives in warm salt water and needs a point of entry, such as an open wound. It can also be contracted from contaminated seafood and often occurs in hospitals, infecting patients who already have compromised immune systems.
MRSA (methicillin-resistant staphylococcus aureus) is a drug-resistant super bug. It can cause a number of serious skin infections and becomes life threatening when it spreads to internal organs. One form of MRSA has been known to attack hospital patients being treated for other conditions.
Insurance on the front lines
No matter what disease you may acquire, if you have health insurance, it will pay up to the policy limits for diagnosis, treatment and prescription drugs, as long as it’s medically necessary.
"Our medical policies outline what treatment and diagnostic tests are covered," says Dr. Virginia Calega, Vice President of Medical Management and Policy for health insurer Highmark, Inc. "Clinicians submit claims for services they have provided. If an antibiotic has been administered, we would cover the treatment, regardless of how exotic the illness, as long as it has regulatory approval, proven efficacy and a positive patient outcome."
Calega adds that health insurance companies typically follow guidelines provided by the American Medical Association, National Institutes of Health, National Institute of Allergy and Infectious Diseases, CDC, FDA and others to determine the effectiveness of treatments for infectious diseases.
Health insurers are trying to hit moving targets that include paying for new diagnostic tests for emerging virus strains, providing access to infectious-disease specialists and identifying the latest medical technology in order to treat diseases that may not be well-documented.
As long as your treatment is medically necessary and proven effective, your health plan will pay up to its policy limits. Group health plans purchased through work generally have broad coverage for preventive care, medical treatment and prescriptions. Individual health coverage purchased on the private market varies widely. Some plans cover preventive care such as vaccinations for infectious diseases and disease specialists, while others do not.
The National Association of Health Underwriters defines "medical necessity" as a prescribed medical procedure that is "considered effective and is normally used for the specified illness or injury and does not exceed in scope, duration or intensity of the level of care needed to provide safe, adequate and appropriate diagnosis or treatment."
"Investigational" treatments fall outside insurance coverage. For example, UnitedHealthcare would cover a service to "prevent, diagnose or treat a sickness or injury" unless it is "investigational, unproven, custodial, cosmetic or explicitly excluded in the policy."
Occasionally payment for treatment will fall squarely on a hospital — if you acquire the condition in the hospital while being treated for something else. That’s the case with MRSA, the staph infection that’s resistant to most antibiotics.