Check out this quiz that appeared on Yahoo News this past Sunday.

Quick quiz: What do these enterprises have in common? Farm and construction machinery, Tupperware, the railroads, Hershey sweets, Yum food brands and Yahoo? Answer: They’re all more profitable than the health insurance industry.

The article written by an Associated Press reporter went on to point out that in the health care debate, Democrats and their allies have gone after insurance companies as rapacious profiteers making “immoral” and “obscene” returns while “the bodies pile up.”

The Associated Press notes that ledgers tell a different story. Here are the numbers:

Health insurers posted a 2.2 percent profit margin last year, placing them 35th on the Fortune 500 list of top industries. As is typical, other health sectors did much better — drugs and medical products and services were both in the top 10.

The railroads brought in a 12.6 percent profit margin. Leading the list: network and other communications equipment, at 20.4 percent.

HealthSpring, the best performer in the health insurance industry, posted 5.4 percent. That’s a less profitable margin than was achieved by the makers of Tupperware, Clorox bleach and Molson and Coors beers.

The star among the health insurance companies did, however, nose out Jack in the Box restaurants, which only achieved a 4 percent margin.

UnitedHealth Group, reporting third quarter results last week, saw fortunes improve. It managed a 5 percent profit margin on an 8 percent growth in revenue.

By the way, Bloomberg is reporting this morning that insurers’ stocks fell 2.5 percent yesterday. The reason? Senate Democratic Leader Harry Reid said he will ask the U.S. Senate to vote for a government-run health-insurance program that would allow states to opt out.

That should teach those rapacious profiteers a lesson.

During this week’s healthcare Town Hall Meeting in Portsmouth, NH, President Obama said, “Where we do disagree, let’s disagree over things that are real, not these wild misrepresentations.”

After hearing some of the wild misrepresentations – even some of which that have come from political pros who should know better – I agree. Let’s keep the debate real.

So for starters, let’s talk about the promise that we keep hearing about keeping our current plan if we like it. President Obama has repeatedly told the American public, “If you like your health care plan, you’ll be able to keep your health care plan, period. No one will take it away, no matter what.”

That sounds good. It is suppose it is to make us feel secure in the fact that we will not all be forced to join some public plan that would make us change doctors and wait in line for treatment. It just is not true.

Take for instance Health Saving Accounts. According to America’s Health Insurance Plans (AHIP), there are at least 8 million people enrolled in these types of health plans which couple a lower premium with a higher deductible and a tax-advantaged Health Savings Account (HSA) that can be used to pay for a large number of health care needs.

These HSA plans are in jeopardy of going away under the health reform legislation that has come out of three House committees and one Senate panel that have drafted the  legislation as it stands today.

Why? Let’s look at Section 122 of HR 3200, the House version of the bill. This section is intended to set standards for all health plans guaranteeing that Americans will have access to essential benefits – as defined by the federal government.

One test of whether a plan meets the minimum benefits standards is something called Minimum Actuarial Value. Here is how this is defined in the bill:

Section 122 (3) MINIMUM ACTUARIAL VALUE-IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).

Depending upon the method used to calculate this 70 percent of the full actuarial value the benefits provided consumer-directed health plans as we know them today could go away. So much for keeping the plan that you have and that you like. Without overtly being singled out in the legislation, HSAs would effectively be rendered illegal under this bill because they would not meet the government’s definition of minimum benefits.

This is despite the fact that in a report dated May 2009, the American Academy of Actuaries, says that, with respect to consumer-directed health care plans:

“Generally, all of the studies indicated that cost savings did not result from avoidance of appropriate care and that necessary care was received in equal or greater degrees relative to traditional plans.  All of the studies reviewed reported a significant increase in preventive services for CDH [consumer directed healthcare] participants. Three of the studies found that CDH plan participants received recommended care for chronic conditions at the same or higher level than traditional (non-CDH) plan participants. Two studies reported a higher incidence of physicians following evidence-based care protocols.”

Does it make sense to effectively kill a health insurance approach that has proven its ability to reduce costs while placing increased emphasis on preventive care? I thought that these were major goals for the reform package. Eight million people are going to be very disappointed to learn that they were not told the truth by their President and their Congressional delegates.

But hold on, there is still some hope that Congress will correct this situation before a final bill is rendered for a vote. One of the final amendments to HR 3200 offered up during the House Education and Labor Committee mark-up of the bill may help you hang onto your HSA at least a little longer – IF you are part of a group plan.

Submitted by Rep. Petri (R- WI), and accepted by unanimous consent of the committee, was an amendment that placed at the end of subsection 102 of HR 3200 language to provide an exception to consumer-directed health plans and arrangements. In part the amendment says, “…in the case of a group health plan which consists of a consumer-directed health plan or arrangement (including a high deductible health plan within the meaning of section 223 (c) (2) of the Internal Revenue Code of 1986), such group plan shall be treated as acceptable coverage under a current group health plan for purposes of this division.”

Section 102 of HR 3200 (in case you have lost track) is the part of the House bill that says it will protect your choice to keep your current coverage. It grandfathers existing group health plans for five years before they will have to comply with the government’s idea of what a health plan should consist. If you have an individual plan today, you will not be guaranteed that you can keep you current plan as the bill stands now.

The Petri amendment is a start to protecting consumer-directed health plans and HSAs, but even it has a long way to go to make it into the final bill. When Congress reconvenes in September the three House bills on healthcare reform will need to be merged to produce a final consolidated version that can be voted on by the entire House.

Meanwhile, two committees in the Senate have also taken up healthcare reform. The Committee on Health, Education, Labor, and Pensions (HELP), chaired by Sen. Ted Kennedy (D-MA), and the Senate Finance Committee chaired by Sen. Max Baucus (D-MT).

Of these two committees, the Finance Committee is attempting to develop the most bi-partisan bill and has yet to present a final draft for mark-up.

The committee has reached out to many sectors for input on the legislation they are drafting. One group they consulted was the HSA Council which has proposed language to the committee that would allow for HSA-type plans to meet the actuarial minimal requirement that no doubt will be in the bill they are now writing.

In a memo to a committee staffer dated July 30, 2009, Kevin McKechnie, staff director of the HSA Council, acknowledged that “…considerable confusion can exist on how to establish the actuarial value of HSAs.” He suggested the following definition be adopted by the committee:

“In determining the actuarial value of an HSA qualified HDHP, this amount must recognize both the value of the HSA qualified contribution to the Health Savings Account from any source and the health insurance benefits.”

By making the contributions made to HSAs by employees and their employers count towards actuarial minimum requirement HSAs could continue to be a viable and useful plan option well into the future.

If you have an HSA and you want to keep it now is the time to act. Help President Obama and this Congress keep the promise they have been making to us. Contact a member of the Senate Finance Committee and ask them to endorse the adoption of the above language in their bill. While you’re at it let your representatives know that you would like to see similar language in the House version of the bill.

This certainly isn’t as much fun as showing up at a town hall meeting and telling your elected representative where you think he/she should spend their after-life. Nor, is it as entertaining as speculating about some eerie death panel that would convene to tell us when to pull the plug on grandma. For eight million Americans this is real, and now, according to the President, is the time to disagree about the things in healthcare reform legislation that are real.

According to a press release issued by the Kaiser Family Foundation, a solid majority of the American people (61%) continue to believe that health reform is more important than ever given the country’s economic problems; sizeable majorities support key elements of reform currently being debated such as employer mandates (69%), individual mandates (71%), and a public plan option (65-67% depending on wording).

However, as seen in previous polls less than half of the public (41%) say they are willing to pay more for health reform, with a similar number supporting changing the tax treatment of employer based health insurance (40%), one of the major revenue raisers being discussed. Overall opinion, according to the release, remains highly moveable, with support for many elements of reform susceptible to arguments pro and con and often moving by as much as 40 percentage points when arguments are tested.

These poll results speak volumes about the complexity and the emotions of this issue. Sure, everyone can agree on the conceptual issues of access, affordability and quality, but when it comes to the harder questions of figuring out who will pay, and for how much, there is still a tremendous amount of disagreement. Special interest groups are now closing ranks to protect their piece of the healthcare pie.

More casual supporters of the concept are likely to cast a skeptical eye on healthcare reform efforts after they read about today’s announcement from the Congressional Budget Office that said the Senate Health, Education, Labor and Pensions Committee health reform legislation would cost the government an estimated $1 trillion over the next 10 years while reducing the number of uninsured U.S. residents by about one-third, or 16 million people.

This has sent the powerful tax-writing House of Representatives Ways and Means Committee looking for more money and their Chairman Charles Rangel, D-N.Y. aims to have proposals by Friday to help pay the trillion dollar tab.

According to a Reuters report, among the proposals Rep. Rangel is expected to announce by Friday are cuts to private plans that operate in the Medicare Advantage health program for seniors. Rep. Rangel also said the panel was weighing the “depth” of the subsidies that low-income people might get under any health reform legislation.

I am still confused about why this discussion centers so much on buying health insurance coverage instead of the real issue which is providing opportunities for Americans to achieve better health. Would it really cost a trillion dollars to make us all healthier and less dependent on expensive medical treatments? Isn’t that what we are really trying to do here? If we just focus on devising ways to pay for care once we get sick – mostly because of lifestyle choices – we had better have a lot of money to throw at this problem and the last time I checked, we didn’t.

It is far too easy sometimes to get ourselves bogged down in the intricacies of a debate. Take healthcare for instance. We can talk about the merits of having a public health plan versus the benefits of having the private sector use its innovation to show us the way out of the growing financial woes being caused by our current healthcare system.

Once in a while we need a slap in the face, a cold shower, that Americano with no room for cream.  That is exactly what John A. Kitzhaber, MD, Governor of Oregon 1995-2003, delivered to those gathered to hear the keynote address this morning at AHIP Institute in San Diego, CA.

The third wheel on a panel that featured Jeb Bush, the former Governor of the State of Florida and Howard Dean, MD, Chairman, Democratic National Committee, 2005-2009; Founder, Democracy for America, and the former Governor of Vermont, Kitzhaber stole the show.

Dressed in a jacket, white shirt, tie, pressed blue jeans and cowboy boots, Kitzharber made no bones about the fact that we are borrowing from our kids to pay for health care today. But, rather than dwelling of the finer details of how to fix the current system to provide coverage to more people, Kitzharber told the representatives of America’s health insurance plans that they were missing the point and needed to change their business model.

“Healthcare is a means to an end,” he said. “The end is health.”

Kitzharber noted that most of the factors that contribute to poor health in this country have nothing to do with access to health insurance coverage. They are lifestyle choices, environmental issues and so fourth.

If we really want to address health, we need to work on developing a system that promotes health and not one that is not geared towards spending massive amounts of money on people after they have reached a health crisis that could have been prevented with the proper emphasis in prevention and wellness.

I think that slap in the face was exactly what this audience needed, and I think they knew it too judging by the amount of applause Kizthaber received for his comments.

A thoughtful piece on healthcare reform appeared yesterday on the HealthLeaders website, www.healthleadersmedia .com.

In an article entitled “It’s Time to Pay Primary Care More,” Elyas Bakhtiari noted that at a time when Democratic leaders in Congress prepare to introduce healthcare reform legislation, the Obama administration is expressing concern about the growing primary care doctor shortage and exploring ways to increase physician supply.

Bakhtiari applauded the national healthcare reform architects for paying attention to previous efforts in Massachusetts, where the promise of universal coverage has fizzled somewhat, in part because of a primary care shortage. He writes that faced with inadequate primary care access, patients are showing up at emergency rooms and adding to overall costs-ED visits have risen 7% and the cost of emergency care has climbed 17% in Massachusetts in the past two years.

Causing the shortage in primary care docs, Bakhtiari points out, is that primary care doesn’t pay enough to lure many of today’s medical students. He notes that when presented with the options of making $180,000 as a family practitioner and $400,000 or more as a proceduralist, students are increasingly choosing the latter.

Bakhtiari then points to the large government-run healthcare programs as driving this shortage. The pool of dollars for reimbursing physicians for Medicare and Medicaid is limited, writes Bakhtiari. And, he says, that while the payment disparity has benefited certain surgeons and specialists, the damage caused by a lack of primary care physicians affects the entire healthcare system.

The conclusion that Bakhtiari reaches is that reforming the entire healthcare system can only be done by making some very hard choices such as increasing payment to primary care at the expense of some of the higher-paid specialists.

It appears that the Congressional architects of healthcare reform may have gotten this same message. On Wednesday of this week, the New York Times reported that Senator Max Baucus, (D MT), and Senator Charles E. Grassley (R IW), had unveiled a set of detailed recommendations intended to slow the growth of Medicare, hold doctors and hospitals more accountable, and improve the care of patients with chronic illnesses.

Key to this effort, The Times said, is a proposed 5 percent bonus payment for office visits and other “primary care services” provided to Medicare patients by family doctors and internists. General surgeons in rural areas would receive a similar bonus, but Medicare payments to many other specialists would be reduced.

Of course, this proposal has made many providers nervous, but it is, I think, a step in the right direction. Government programs like Medicare and Medicaid now provide coverage for about half of our population. If healthcare reform developed this year contains a “Public Plan” option that would be available to the working population, this percentage will skyrocket. It is time that these programs are used help shape healthcare delivery into a more efficient, cost effective system.

A new study released today said that, despite the recession and recent cutbacks in some benefit programs, companies continue to add wellness and health management programs to promote healthier behaviors among their workers.

The survey conducted by Watson Wyatt, a leading global consulting firm, and the National Business Group on Health (NBGH), an association of more than 300 mostly large employers also found that companies are finding greater success by offering workers financial incentives for participation in these programs.

Employer interest in programs that promote a healthier workforce continues to increase, the survey found. For example, nearly six in 10 companies (58 percent) offer lifestyle improvement programs, up from 43 percent in 2007, while 56 percent offer health coaches compared with 44 percent in 2007. The number of weight management programs is also on the rise, offered by 52 percent of companies, up from 42 percent in 2007. Also, health risk appraisals are offered by 80 percent of companies, up from 72 percent in 2007, according to the survey of 489 large U.S. employers conducted in January.

Companies that offer financial incentives report significantly higher participation in lifestyle management and wellness programs, according to the survey. Incentives for health risk appraisals are on the rise, offered by 61 percent of employers, up from 53 percent in 2008. Other programs that frequently offer incentives to encourage use include those for smoking cessation (offered by 40 percent of employers in both 2008 and 2009), weight management (offered by 34 percent of employers, up from 31 percent in 2008) and full coverage of preventive services (offered by 73 percent, up from 53 percent last year).

According to the survey, even moderate incentives can help engage employees in healthy behaviors. Financial incentives between $51 and $100 can boost participation in smoking cessation and weight management programs and encourage workers to get biometric screenings. Higher participation in health risk appraisals is associated with incentives greater than $100.

This survey coincides with another report out today that quoted Safeway Inc. president Steven Burd. He said that making employees at the third-largest North American supermarket chain accountable for their weight, smoking, cholesterol and blood pressure, has saved millions. Burd proposed the highly praised program used by his company as a model not only to other companies, but to the federal government.

“If you are part of a large organization, you really don’t have to wait for government to do anything,” Burd told the World Health Care Congress being held in Washington. “You can design your own healthcare reform.

Healthcare costs Safeway $1 billion a year for 200,000 employees, Burd said, adding that the program had held those costs level since 2005.

Once again we find that some of the most effective ways to reform healthcare is to reform ourselves.

To view the 14th annual NBGH/Watson Wyatt report, visit www.watsonwyatt.com/2009nbghsurvey.

An article appeared today in the Drug Benefits News, that draws attention to a situation where health plans are struggling to keep up with evolving technology. The article, written by Neal Learner, notes that the pace of personalized medicine is accelerating, with roughly a dozen new therapies expected to hit the market between now and mid-2010 that will be paired with a genetic test.

Learner writes that proponents of the use of personalized medicine are saying that it will become increasingly popular in the coming years as both providers and payers recognize the ability of tailored therapies to enhance the practice of medicine and reduce costs over time, including by avoiding adverse events.

Felix Frueh, vice president of personalized medicine research and development at Medco Health Solutions, Inc., is quoted in the article as saying that potential savings from the use of genomic testing include a reduction in the number of hospitalizations and physician visits because patients are put on the right medication at the right dose earlier.

The question now is which of these tests have benefit and which do not.

Learner writes that Frueh told the told a Feb. 26 AIS audioconference on personalized medicine that, “Pharmacogenomic outcome studies are key and critically important, and they are also growing in number. In the next few years, we will see the results of many of these studies [that] really help us make decisions on whether or not the clinical impact is sufficient and the economic considerations are affordable.”

Health plans will be paying close attention to the results of these studies to determine which of these tests to cover under their health policies.  Learner notes that Lynn Nishida, director of pharmacy services at Regence says the value of many marketed genetic tests is unknown, adding that the tests may range in price from $50 to $2,000 and higher.

In designing policies, health plans should first identify the tests that can be automatically approved, she said. “What you’re trying to do is narrow down your focus to those genetic tests that you are going to have a more thorough review for medical records,” she said of the tests that may be considered investigational or have not yet been shown to have value.

Like any new technology, insurance companies will struggle with which genomic tests to approve, under what circumstances. This will no doubt create controversy and once again draw charges of carriers playing “god” in making coverage decisions. Could this be a place where comparative effectiveness research conducted at the national level could lead to some consistency among health plans while it creates efficiencies by eliminating the need for each carrier to conduct their own research?

Critics will say that this the government rationing care, but someone — carriers or the government — will need to develop standards for these types of tests.  In 2007, Regence received 55,100 medical claims for genetic tests, representing more than $5 million in billed claims, and this is just the tip of the ice burg.