Primary health care

Primary health care


Medical train "Therapist Matvei Mudrov" in Khabarovsk, Russia
Primary care is the term for the health care services which play a role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system.
Such a professional would usually be a primary care physician, such as a general practitioner or family physician, or a non-physician primary care provider, such as a physician assistant or nurse practitioner. Depending on the locality, health system organization, and sometimes at the patient's discretion, they may see another health care professional first, such as a pharmacist, a nurse (such as in the United Kingdom), a clinical officer (such as in parts of Africa), or an Ayurvedic or other traditional medicine professional (such as in parts of Asia). Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.

Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care by the reason for the patient visit.

Common chronic illnesses usually treated in primary care may include, for example: hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.
In context of global population aging, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected around the world, in both developed and developing countries.

The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy.

Secondary health care

Secondary health care

Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists.

It includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury or other health condition, such as in a hospital emergency department. It also includes skilled attendance during childbirth, intensive care, and medical imaging services.
The "secondary care" is sometimes used synonymously with "hospital care". However many secondary care providers do not necessarily work in hospitals, such as psychiatrists, clinical psychologists, occupational therapists or physiotherapists, and some primary care services are delivered within hospitals. Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care.

For example in the United States, which operates under a mixed market health care system, some physicians might voluntarily limit their practice to secondary care by requiring patients to see a primary care provider first, or this restriction may be imposed under the terms of the payment agreements in private/group health insurance plans. In other cases medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred.
In the United Kingdom and Canada, patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician (either a primary care physician or another specialist) is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance.
Allied health professionals, such as physical therapists, respiratory therapists, occupational therapists, speech therapists, and dietitians, also generally work in secondary care, accessed through either patient self-referral or through physician referral.

Health care financing

Health care financing
Health care system, Health policy, and Universal health care
There are generally five primary methods of funding health care systems:

general taxation to the state, county or municipality
social health insurance
voluntary or private health insurance
out-of-pocket payments
donations to health charities


In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.
For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

affordable Care Act is Working to Bring Down Health Care Costs

affordable Care Act is Working to Bring Down Health Care Costs


Before the Affordable Care Act passed, the dramatic rise in health care costs put access to health care coverage out of reach for many Americans. With many people no longer able to afford coverage, the cost of uncompensated care in hospitals rose and those costs were passed along to people that could afford coverage. And, at the same time, health care’s share of the nation’s economy was growing rapidly.

Three years later, the Affordable Care Act is working to bring down health care costs.

The law includes innovative tools to drive down health care costs.  It incentivizes efficient care, supports a robust health information technology infrastructure, and fights fraud and waste.   After decades of growing faster than the economy, last year, Medicare costs grew by only four-tenths of a percent per person, continuing the trend of historically low Medicare growth seen in 2011 and 2010.

Major progress in Medicare is sparking smarter care in the private market, and it’s working to bring down costs in the private market. Overall health-care costs grew more slowly than the rest of the economy in 2011 for the first time in more than a decade. And just last week, USA Today  reported health care providers and analysts found that “cost-saving measures under the health care law appear to be keeping medical prices flat.”

Even though the health care law is working to bring down costs, critics continue to claim the law is too expensive.  In reality, the law is fully paid for, and according to the independent Congressional Budget Office, the law reduces the deficit over the long term.  The facts show that employers, patients and our federal budget can’t afford to roll back the law now:

Fully repealing the Affordable Care Act would increase the deficit by $100 billion over ten years and more than a trillion dollars in the next decade.  It would also shorten the life of the Medicare Trust Fund by eight years.
Health care spending grew by 3.9% in 2011, continuing for the third consecutive year the slowest growth rate in fifty years.
Health-care costs grew slower than the rest of the economy in 2011 for the first time in more than a decade.
The proportion of requests for double-digit premium increases plummeted from 75% in 2010 to 14% so far in 2013.
Medicaid spending per beneficiary decreased by 1.9% from 2011 to 2012.
Medicare spending per beneficiary grew by only 0.4% in fiscal year 2012.
Slower growth is projected to reduce Medicare and Medicaid expenditures by 15% or $200 billion by 2020 compared to what those programs would have spent without this slowdown, according to CBO.
At the same time the law is driving down cost growth, the Affordable Care Act is strengthening coverage and expanding coverage.  Thanks to the law, more than 34 million people with Medicare received a no-cost preventive service.  And, over six million Medicare beneficiaries received $5.7 billion in prescription drug discounts.

Some have proposed turning Medicare into a voucher program--undercutting the guaranteed benefits that seniors have earned and forcing them to pay thousands more out of their own pockets.  If we turn Medicare into a voucher program, our system doesn’t have any incentives to be more efficient and lower costs.  Instead, as costs rise, vouchers will leave seniors to pay more and more out of their own pocket.

The health care law is working to lower costs, increase efficiency, and deliver better patient outcomes – without cutting costs at seniors’ expense.  In recent years, we have seen dramatic slowing of the growth of federal health care programs.  The best approach to reducing our deficit is to continue implementing common-sense reforms.  The health care law is putting us on the right path to make Medicare and Medicaid stronger, more efficient and less costly.

affordable Care Act is Working to Bring Down Health Care Costs

affordable Care Act is Working to Bring Down Health Care Costs


Before the Affordable Care Act passed, the dramatic rise in health care costs put access to health care coverage out of reach for many Americans. With many people no longer able to afford coverage, the cost of uncompensated care in hospitals rose and those costs were passed along to people that could afford coverage. And, at the same time, health care’s share of the nation’s economy was growing rapidly.

Three years later, the Affordable Care Act is working to bring down health care costs.

The law includes innovative tools to drive down health care costs.  It incentivizes efficient care, supports a robust health information technology infrastructure, and fights fraud and waste.   After decades of growing faster than the economy, last year, Medicare costs grew by only four-tenths of a percent per person, continuing the trend of historically low Medicare growth seen in 2011 and 2010.

Major progress in Medicare is sparking smarter care in the private market, and it’s working to bring down costs in the private market. Overall health-care costs grew more slowly than the rest of the economy in 2011 for the first time in more than a decade. And just last week, USA Today  reported health care providers and analysts found that “cost-saving measures under the health care law appear to be keeping medical prices flat.”

Even though the health care law is working to bring down costs, critics continue to claim the law is too expensive.  In reality, the law is fully paid for, and according to the independent Congressional Budget Office, the law reduces the deficit over the long term.  The facts show that employers, patients and our federal budget can’t afford to roll back the law now:

Fully repealing the Affordable Care Act would increase the deficit by $100 billion over ten years and more than a trillion dollars in the next decade.  It would also shorten the life of the Medicare Trust Fund by eight years.
Health care spending grew by 3.9% in 2011, continuing for the third consecutive year the slowest growth rate in fifty years.
Health-care costs grew slower than the rest of the economy in 2011 for the first time in more than a decade.
The proportion of requests for double-digit premium increases plummeted from 75% in 2010 to 14% so far in 2013.
Medicaid spending per beneficiary decreased by 1.9% from 2011 to 2012.
Medicare spending per beneficiary grew by only 0.4% in fiscal year 2012.
Slower growth is projected to reduce Medicare and Medicaid expenditures by 15% or $200 billion by 2020 compared to what those programs would have spent without this slowdown, according to CBO.
At the same time the law is driving down cost growth, the Affordable Care Act is strengthening coverage and expanding coverage.  Thanks to the law, more than 34 million people with Medicare received a no-cost preventive service.  And, over six million Medicare beneficiaries received $5.7 billion in prescription drug discounts.

Some have proposed turning Medicare into a voucher program--undercutting the guaranteed benefits that seniors have earned and forcing them to pay thousands more out of their own pockets.  If we turn Medicare into a voucher program, our system doesn’t have any incentives to be more efficient and lower costs.  Instead, as costs rise, vouchers will leave seniors to pay more and more out of their own pocket.

The health care law is working to lower costs, increase efficiency, and deliver better patient outcomes – without cutting costs at seniors’ expense.  In recent years, we have seen dramatic slowing of the growth of federal health care programs.  The best approach to reducing our deficit is to continue implementing common-sense reforms.  The health care law is putting us on the right path to make Medicare and Medicaid stronger, more efficient and less costly.

Shortages of health professionals

Shortages of health professionals
Health workforce, Doctor shortage, and Nursing shortage

Many jurisdictions report shortfalls in the number of trained health human resources to meet population health needs and/or service delivery targets, especially in medically underserved areas. For example, in the United States, the 2010 federal budget invested $330 million to increase the number of doctors, nurses, and dentists practicing in areas of the country experiencing shortages of health professionals. The Budget expands loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas. This funding will enhance the capacity of nursing schools to increase the number of nurses. It will also allow states to increase access to oral health care through dental workforce development grants. The Budget’s new resources will sustain the expansion of the health care workforce funded in the Recovery Act.
In Canada, the 2011 federal budget announced a Canada Student Loan forgiveness programme to encourage and support new family physicians, nurse practitioners and nurses to practise in underserved rural or remote communities of the country, including communities that provide health services to First Nations and Inuit populations.
In Uganda, the Ministry of Health reports that as many as 50% of staffing positions for health workers in rural and underserved areas remain vacant. As of early 2011, the Ministry was conducting research and costing analyses to determine the most appropriate attraction and retention packages for medical officers, nursing officers, pharmacists, and laboratory technicians in the country’s rural areas.

At the international level, the World Health Organization estimates a shortage of almost 4.3 million doctors, midwives, nurses, and support workers worldwide to meet target coverage levels of essential primary health care interventions.

 The shortage is reported most severe in 57 of the poorest countries, especially in sub-Saharan Africa.

Health care research

The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment. Many important advances have been made through health research, including bio medical research and pharmaceutical research. They form the basis of evidence-based medicine and evidence-based practice in health care delivery.

For example, in terms of pharmaceutical research and development spending, Europe spends a little less than the United States (€22.50bn compared to €27.05bn in 2006).

The United States accounts for 80% of the world's research and development spending in biotechnology.

In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make population healthier.

 Results from health services research often form the basis of evidence-based policy in health care systems. Health services research is also aided by initiatives in the field of AI for the development of systems of health assessment that are clinically useful, timely, sensitive to change, culturally sensitive, low burden, low cost, involving for the patient and built into standard procedures.

Health care providers

 Health care providers


Primary care may be provided in community health centres.
The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams.

This includes professionals in medicine, nursing, dentistry and allied health, plus many others such as public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based preventive, curative and rehabilitative care services.
While the definitions of the various types of health care vary depending on the different cultural, political, organizational and disciplinary perspectives, there appears to be some consensus that primary care constitutes the first element of a continuing health care process, that may also include the provision of secondary and tertiary levels of care. Healthcare can be defined as either public or private healthcare

Health care financing

Health care financing
Health care system, Health policy, and Universal health care
There are generally five primary methods of funding health care systems:

general taxation to the state, county or municipality
social health insurance
voluntary or private health insurance
out-of-pocket payments
donations to health charities


In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.
For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

Health care financing
See also: Health care system, Health policy, and Universal health care
There are generally five primary methods of funding health care systems:
general taxation to the state, county or municipality
social health insurance
voluntary or private health insurance
out-of-pocket payments
donations to health charities


In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.
For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

Health care financing
See also: Health care system, Health policy, and Universal health care
There are generally five primary methods of funding health care systems:
general taxation to the state, county or municipality
social health insurance
voluntary or private health insurance
out-of-pocket payments
donations to health charities
In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.
For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

Health care financing
See also: Health care system, Health policy, and Universal health care
There are generally five primary methods of funding health care systems:
general taxation to the state, county or municipality
social health insurance
voluntary or private health insurance
out-of-pocket payments
donations to health charities


In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.
For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

Primary health care


Medical train "Therapist Matvei Mudrov" in Khabarovsk, Russia
Primary care is the term for the health care services which play a role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system.[6][7] Such a professional would usually be a primary care physician, such as a general practitioner or family physician, or a non-physician primary care provider, such as a physician assistant or nurse practitioner. Depending on the locality, health system organization, and sometimes at the patient's discretion, they may see another health care professional first, such as a pharmacist, a nurse (such as in the United Kingdom), a clinical officer (such as in parts of Africa), or an Ayurvedic or other traditional medicine professional (such as in parts of Asia). Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.
Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care by the reason for the patient visit.

Common chronic illnesses usually treated in primary care may include, for example: hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.
In context of global population aging, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected around the world, in both developed and developing countries.

The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy.

Health care (or healthcare) information

Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers. It refers to the work done in providing primary care, secondary care and tertiary care, as well as in public health.
Health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making” (Brailer, & Thompson, 2004). Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT.

Access to health care varies across countries, groups and individuals, largely influenced by social and economic conditions as well as the health policies in place. Countries and jurisdictions have different policies and plans in relation to the personal and population-based health care goals within their societies. Health care systems are organizations established to meet the health needs of target populations. Their exact configuration varies from country to country. In some countries and jurisdictions, health care planning is distributed among market participants, whereas in others planning is made more centrally among governments or other coordinating bodies. In all cases, according to the World Health Organization (WHO), a well-functioning health care system requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality medicines and technologies.

Health care can form a significant part of a country's economy. In 2008, the health care industry consumed an average of 9.0 percent of the gross domestic product (GDP) across the most developed OECD countries.

The United States (16.0%), France (11.2%), and Switzerland (10.7%) were the top three spenders.
Health care is conventionally regarded as an important determinant in promoting the general health and well-being of people around the world. An example of this is the worldwide eradication of smallpox in 1980—declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions

Small Businesses Pursue Health Law ‘Loophole’

NorthBay Adventure is the kind of small business that could be expected to buy medical insurance for workers under sweeping health-act rules taking effect in 2014. But executive director George Comfort says that’s not likely to happen.

Instead, NorthBay became self-insured last year, paying most of its workers’ health costs directly, a practice more typical of large employers.  The decision to self-insure was about free choice, savings and what’s best for his company, Comfort says.


George Comfort, NorthBay Adventure's executive director, found he could save money on health coverage for his young workforce by self-insuring (Photoby Kyle Grantham for USA TODAY).
But others see it as a threat to the Affordable Care Act. As more small employers like NorthBay avoid the health act’s requirements through self-coverage, small-business marketplaces intended to cover millions of Americans could break down and become unaffordable, they say.

“What you’ve got is basically a loophole for the small employer to get out of the ACA requirements,” says Robert Laszewski, a Virginia-based consultant and former insurance executive.

To employees, medical self-insurance looks like a regular health plan. Self-insured employers pay for most worker health costs directly, though they contract with an insurer or other company to administer claims. The employers also buy coverage known as stop-loss for claims exceeding a certain amount. Brokers say a growing number of firms see such plans as low-cost alternatives to conventional coverage because they’re exempt from ACA requirements such as insurance taxes and specified benefits.

NorthBay, which is located on the north shore of Maryland’s Chesapeake Bay and delivers outdoors education to sixth-graders, saves some 45 percent on self-insured health costs for its 60 or so covered employees compared with the price of regular coverage, says Comfort.

“We have a very young workforce,” says Comfort. “Our average age is at or below 30. So we have a very healthy group.”

But if too many small companies take a similar route, insurance plans for small businesses will be stuck with older and sicker members, say policy scholars.

Under some conditions, such a dynamic could drive up the cost of traditional insurance by as much as 25 percent, says Matthew Buettgens, a researcher at the Urban Institute, at a time when many already worry about the affordability of coverage next year.

“If it becomes too easy to self-insure, you’re inviting employers to choose one kind of coverage if their workers are healthy and a different kind of coverage if they’re sick,” says Mark Hall, a law professor at Wake Forest University.

That undermines a basic feature of the exchanges: the “community rating” obliging insurers to offer similar prices to all comers, spreading the cost of care among well and sick alike. In a worst-case scenario, small employers will self-insure when workers are healthy, avoiding community rating, and then immediately buy price-controlled coverage on the exchanges if someone becomes gravely ill.

Health-act advocates especially worry that firms with fewer than 50 employees will self-insure. Those companies aren’t required to offer policies under the health law but many are expected to buy in online marketplaces, also known as exchanges, scheduled to open in October.

However, self-insurance might be the only way some struggling employers can afford medical coverage, says Michael Ferguson, chief operating officer at the Self-Insurance Institute of America, an industry group.

Even so, he disputes the notion that firms and stop-loss companies can “cherry pick” the system by self-insuring only when workers appear healthy. Even young people have accidents and get sick, he says, adding that companies often know less about employees’ health than they think.

“The idea about employers gaming the system is just a canard,” he says.

The key to self-insurance for small companies is stop-loss coverage, which often kicks in when medical costs per worker are as low as $10,000 or $20,000, limiting the employer’s risk almost as well as a regular plan. Brokers report brisk sales of self-insured plans and this backstop coverage.


NorthBay Adventure employee Tyler Douglas, right, hooks up camper Jordan Lofton, 11, to a zip line on March 13 (Photo by Kyle Grantham for USA TODAY).
“Last year we saw a huge uptake of self-funded or partial self-funded business,” says David Fear, a Roseville, Calif., consultant who helps brokers and agents issue stop-loss coverage.

The average size of self-insured companies Fear handles is between 25 and 30 workers, he estimates. His business for firms with fewer than 100 employees doubled in the last year, he says.

At BSI Strategic Consulting, a Fresno, Calif., firm that helps small companies self-insure, “our business has more than doubled in the last six months,” says CEO Lawrence Thompson. “There’s a lot more interest in self-funding than I’ve seen in the last 32 years.”

At insurance giant Cigna, self-coverage for small employers grew by a fifth last year, says Julie McCarter, vice president of product development for Cigna Select, which sells medical stop-loss coverage and claims processing.

“A lot of it comes down to what’s going on in Washington,” says Donald Drelich, CEO of D.W. Van Dyke, a Connecticut insurance consultant. “People are seeing the cost of insurance rising because of the things that are being added [under the ACA], so they’re exploring other possibilities.”

Self-coverage is exempt from ACA premium taxes estimated to raise prices from 2 percent to 4 percent, as well as from the health law’s “essential benefit” and community rating rules. Employers such as NorthBay’s Comfort say that gives them the flexibility to tailor plans for their workers.

For insurers, there may be another reason to promote stop-loss policies: They aren’t subject to the health act’s limit on profits, which requires at least 80 percent of premiums for small business to be spent on medical care.

Officials in some states are trying to limit self-coverage. California, Rhode Island and Minnesota are considering legislation that raises the point at which stop-loss insurance kicks in, reducing or eliminating small firms’ ability to self-insure.

Two years ago then-New Jersey Commissioner of Banking and Insurance Thomas Considine warned stop-loss insurers to cease “selectively marketing” to small employers with young workers. He pledged to issue regulations prohibiting the practice but, following industry protests, they were never published. A proposal to recommend limiting stop-loss insurance with low trigger thresholds stalled recently at the insurance commissioners’ association, also after industry lobbying.

Last month the self-insurance institute formed an alliance with the National Retail Federation and other business groups to oppose such measures. If the idea behind the ACA is to increase health coverage, such groups ask, why would anybody want to limit small businesses’ ability to offer self-insured plans?

“To the employers it looks like health insurance, it feels like health insurance, and it’s less costly,” says David Burton, general counsel for the National Small Business Association. “Do you want to set up a situation where an IBM or a GM can be self-insured — or even a small company with 100 or 150 employees —and the smaller guys don’t have that option?  I don’t see the logic in that.”

Osteopathic Physicians: An Answer To Rural Health Care Needs?

BLACKSBURG, Va. -- With a tradition more than 100 years old, osteopathic physicians are hardly the new doctors in town. But the profession's recent growth -- in both training facilities and number of graduates -- could help reverse a looming shortage of primary-care providers that experts say will hit rural communities especially hard.

The national shortfall of family doctors, pediatricians and other generalists is expected to reach 52,000 by 2025, according to a study published last year in Annals of Family Medicine. (This study estimated that there were about 209,000 physicians delivering office-based primary care in 2010.) And only 9 percent of physicians practice in rural areas, where 20 percent of the U.S. population lives, according to a 2011 report from the Department of Health and Human Services.

Dr. Valerie Goodman examines Mary Elizabeth
Gardner at Goodman's practice in Centreville, Md.

"That's where osteopaths have been largely helpful - in primary care and especially for those in need," said Brock Slabach, senior vice president for member services at the National Rural Health Association.

And their footprint appears to be growing.

Since 2000, the number of osteopathic medical schools in the United States has increased from 19 to 34, offering about 1,900 new training slots, compared with about 1,600 new positions in MD programs. In 2011, there were about 74,000 osteopathic physicians, compared with about 29,500 in 1990.

Some of that increase is a result of greater acceptance of doctors with osteopathic backgrounds. Although their four-year training includes much of the conventional instruction that medical doctors, or MDs, receive, it also has a heavy focus on the musculoskeletal system and includes a technique called osteopathic manipulative treatment, similar to chiropractic and massage therapy. DOs spend the same amount of time in residency programs and also are required to take board exams for certification.

Until the 1980s, osteopathic doctors often practiced in separate hospitals and clinics; today, that is not the case.

"When I went to school, this was a minority profession that folks didn't know anything about," said Stephen Shannon, president of the American Association of Colleges of Osteopathic Medicine.

Video

An Osteopathic Physician At Work In Rural Maryland:

• Osteopath Aims Wholistic Approach At Filling Primary Care Gap

There are other reasons for the increase, too. Osteopathy programs historically have attracted more older applicants and career changers than MD programs, and recruit applicants in rural locations. The schools are also slightly less expensive and less competitive than many MD programs, though they generally require applicants to take college pre-med classes and the MCAT, or Medical College Admission Test.

A Rural Orientation

Many osteopathic medical schools are springing up in off-the-beaten-path locations - usually to recruit applicants from rural areas and then hope those doctors practice where they grew up.

Take the Edward Via College of Osteopathic Medicine. Founded in 2003, the 1,100-student campus is located in the Blue Ridge Mountains in Blacksburg, Va.

D.O. vs. M.D. Comparison
	DO	MD
Graduates in 2000	2,279	15,718
Graduates in 2011	4,159	17,364
Percent Growth in Number of Graduates	82%	10%
Number of Schools in 2000	19	125
Number of Schools in 2011	34	135
Percent Growth in Number of Schools	79%	8%
Average MCAT Scores of Enrolled (2011-2012)	26.51	31.1
Average GPA of Enrolled (2011-2012)	3.50	3.67
Sources: American Association of Colleges of Osteopathic Medicine, American Association of Medical Colleges, American Medical Association, American Osteopathic Association

James Wolfe, president of Edward Via, said, "Our philosophy is 'Recruit from, educate in, return to.'"

Kari McCoy, a second-year student at Edward Via, fits the profile. She grew up in nearby Floyd, Va., a mountain town with a cluster of country stores around its main intersection, and she hopes to return there to practice preventive medicine when her training is completed.

McCoy, 27, previously a nurse, said Floyd residents can't always get the care they need because local hospitals and private clinics are often crowded or understaffed.

Like many of the communities that dot the Appalachian Mountains, Floyd also has high rates of chronic illness such as heart disease and diabetes. While the location of Edward Via's campus was one reason the school appealed to McCoy, she was also attracted by osteopathy's focus on primary care and prevention, which she believes can help address the needs of her home town.

Reid Blackwelder, president-elect of the American Academy of Family Physicians, a medical society whose members include both MDs and DOs, said the osteopathic philosophy, which dates to 1874, might help explain why 60 percent of new osteopathic medicine graduates gravitate toward primary care, compared with 24 percent of their MD counterparts, many of whom face larger student loans and seek high-paying specialties such as surgery and cardiology.

Hospitals and doctor groups no longer view DOs and MDs differently with respect to primary care, said Cody Futch, senior director of recruiting at the physician employment firm Meritt Hawkins. As a recruiter, he finds that osteopathic physicians generally have the same job opportunities and salaries as medical doctors.

But Futch also acknowledged that in specialized fields such as surgery and cardiology, MD-run practicies might still hesitate when considering how patients will react to the degree. "There is still a little bit of bias by some people, but even that seems more rare," Futch said.

Busy Workload

David Danner, a graduate of Edward Via's debut class, is a family physician in Stuart, a working-class town not far from Blacksburg.

About 20 percent of the population in the surrounding county relies on Medicaid, the state-federal health insurance program for low-income Americans.

Raised on a chicken farm in North Carolina, Danner said he was drawn to osteopathic medicine because of its focus on rural communities and because he knew that DO schools often accepted older students transitioning to a second career after working in textile manufacturing.

Danner, 38, works in one of the town's two clinics, but he wears several hats: He treats 20 patients per day at his office, as well as inmates at a nearby jail and football players at the local high school.

Danner said he makes a good living and is able to practice the "whole-patient approach" he was taught at Edward Via, including manipulative treatments for back pain and muscle tension. He said the three other physicians in his practice, all MDs, also keep up with the latest research and aren't always stretched too thin.

"I think there's a misconception. Just because health care is less [available] in underserved areas doesn't mean providers are underproviding," he said.

BLACKSBURG, Va. -- With a tradition more than 100 years old, osteopathic physicians are hardly the new doctors in town. But the profession's recent growth -- in both training facilities and number of graduates -- could help reverse a looming shortage of primary-care providers that experts say will hit rural communities especially hard.

The national shortfall of family doctors, pediatricians and other generalists is expected to reach 52,000 by 2025, according to a study published last year in Annals of Family Medicine. (This study estimated that there were about 209,000 physicians delivering office-based primary care in 2010.) And only 9 percent of physicians practice in rural areas, where 20 percent of the U.S. population lives, according to a 2011 report from the Department of Health and Human Services.

Dr. Valerie Goodman examines Mary Elizabeth Gardner at Goodman's practice in Centreville, Md.

"That's where osteopaths have been largely helpful - in primary care and especially for those in need," said Brock Slabach, senior vice president for member services at the National Rural Health Association.

And their footprint appears to be growing.

Since 2000, the number of osteopathic medical schools in the United States has increased from 19 to 34, offering about 1,900 new training slots, compared with about 1,600 new positions in MD programs. In 2011, there were about 74,000 osteopathic physicians, compared with about 29,500 in 1990.

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Related story:

• The Mainstreaming Of Osteopathic Medicine

Some of that increase is a result of greater acceptance of doctors with osteopathic backgrounds. Although their four-year training includes much of the conventional instruction that medical doctors, or MDs, receive, it also has a heavy focus on the musculoskeletal system and includes a technique called osteopathic manipulative treatment, similar to chiropractic and massage therapy. DOs spend the same amount of time in residency programs and also are required to take board exams for certification.

Until the 1980s, osteopathic doctors often practiced in separate hospitals and clinics; today, that is not the case.

"When I went to school, this was a minority profession that folks didn't know anything about," said Stephen Shannon, president of the American Association of Colleges of Osteopathic Medicine.

Video

An Osteopathic Physician At Work In Rural Maryland:

• Osteopath Aims Wholistic Approach At Filling Primary Care Gap

There are other reasons for the increase, too. Osteopathy programs historically have attracted more older applicants and career changers than MD programs, and recruit applicants in rural locations. The schools are also slightly less expensive and less competitive than many MD programs, though they generally require applicants to take college pre-med classes and the MCAT, or Medical College Admission Test.

A Rural Orientation

Many osteopathic medical schools are springing up in off-the-beaten-path locations - usually to recruit applicants from rural areas and then hope those doctors practice where they grew up.

Take the Edward Via College of Osteopathic Medicine. Founded in 2003, the 1,100-student campus is located in the Blue Ridge Mountains in Blacksburg, Va.

D.O. vs. M.D. Comparison
	DO	MD
Graduates in 2000	2,279	15,718
Graduates in 2011	4,159	17,364
Percent Growth in Number of Graduates	82%	10%
Number of Schools in 2000	19	125
Number of Schools in 2011	34	135
Percent Growth in Number of Schools	79%	8%
Average MCAT Scores of Enrolled (2011-2012)	26.51	31.1
Average GPA of Enrolled (2011-2012)	3.50	3.67
Sources: American Association of Colleges of Osteopathic Medicine, American Association of Medical Colleges, American Medical Association, American Osteopathic Association

James Wolfe, president of Edward Via, said, "Our philosophy is 'Recruit from, educate in, return to.'"

Kari McCoy, a second-year student at Edward Via, fits the profile. She grew up in nearby Floyd, Va., a mountain town with a cluster of country stores around its main intersection, and she hopes to return there to practice preventive medicine when her training is completed.

McCoy, 27, previously a nurse, said Floyd residents can't always get the care they need because local hospitals and private clinics are often crowded or understaffed.

Like many of the communities that dot the Appalachian Mountains, Floyd also has high rates of chronic illness such as heart disease and diabetes. While the location of Edward Via's campus was one reason the school appealed to McCoy, she was also attracted by osteopathy's focus on primary care and prevention, which she believes can help address the needs of her home town.

Reid Blackwelder, president-elect of the American Academy of Family Physicians, a medical society whose members include both MDs and DOs, said the osteopathic philosophy, which dates to 1874, might help explain why 60 percent of new osteopathic medicine graduates gravitate toward primary care, compared with 24 percent of their MD counterparts, many of whom face larger student loans and seek high-paying specialties such as surgery and cardiology.

Hospitals and doctor groups no longer view DOs and MDs differently with respect to primary care, said Cody Futch, senior director of recruiting at the physician employment firm Meritt Hawkins. As a recruiter, he finds that osteopathic physicians generally have the same job opportunities and salaries as medical doctors.

But Futch also acknowledged that in specialized fields such as surgery and cardiology, MD-run practicies might still hesitate when considering how patients will react to the degree. "There is still a little bit of bias by some people, but even that seems more rare," Futch said.

Busy Workload

David Danner, a graduate of Edward Via's debut class, is a family physician in Stuart, a working-class town not far from Blacksburg.

About 20 percent of the population in the surrounding county relies on Medicaid, the state-federal health insurance program for low-income Americans.

Raised on a chicken farm in North Carolina, Danner said he was drawn to osteopathic medicine because of its focus on rural communities and because he knew that DO schools often accepted older students transitioning to a second career after working in textile manufacturing.

Danner, 38, works in one of the town's two clinics, but he wears several hats: He treats 20 patients per day at his office, as well as inmates at a nearby jail and football players at the local high school.

Danner said he makes a good living and is able to practice the "whole-patient approach" he was taught at Edward Via, including manipulative treatments for back pain and muscle tension. He said the three other physicians in his practice, all MDs, also keep up with the latest research and aren't always stretched too thin.

"I think there's a misconception. Just because health care is less [available] in underserved areas doesn't mean providers are underproviding," he said.

Medicare Revises Readmissions Penalties – Again

In its effort to crack down on repeat hospitalizations, Medicare has its own readmission: for the second time in six months, it has erred in calculating penalties for more than 1,000 of the nation’s hospitals.

As a result, Medicare has slightly lessened its readmissions penalties for 1,246 hospitals as part of its new program pressuring hospitals to ensure patients stay healthy health after they leave. St. Claire Regional Medical Center in Morehead, Ky., is seeing its penalty drop the most, from 0.93 percent to 0.72 percent of every payment Medicare makes for a patient during the fiscal year that ends in September, according to a Kaiser Health News analysis of the new data, which Medicare published on its website.

Revised Readmissions Penalties

Readmission penalties for individual hospitals are available as:

A printable PDF chart
A downloadable CSV spreadsheet
Medicare also modestly increased the penalties for 226 hospitals. LaSalle General Hospital in Jena, La., will see its penalty grow by the greatest percentage. LaSalle will lose 0.84 percent of each Medicare payment per patient, instead of the 0.65 percent reduction Medicare previously announced.

The payment changes for most hospitals were minute, averaging 0.03 percent of each reimbursement. Overall, hospitals will pay $10 million less in penalties than previously calculated, for a total of $280 million this year. The changes are retroactive to October 2012, when the program began.

The Hospital Readmissions Reduction Program was created by the federal health law. It is part of the first wave of changes the federal government is making to the health care system to have Medicare payments reflect the quality of care patients receive.

In response, hospitals across the country have been hustling to thwart readmissions. Some are giving out free prescriptions to patients who can’t afford them. Others are making check-up appointments and dispatching nurses to patients’ homes.

Last month, Jonathan Blum, a top Medicare official, told a U.S. Senate committee that the national readmission rate dropped to 17.8 percent in the last three months of 2012 “after fluctuating between 18.5 percent and 19.5 percent for the past five years.”

“This decrease is an early sign that our payment and delivery reforms are having an impact,” Blum testified.

Under the program, the government is looking at the number of heart attack, heart failure and pneumonia patients who return to the hospital within 30 days of discharge. Hospitals with more readmissions than Medicare expected given their mix of patients are penalized by losing up to 1 percent of their regular payments. The maximum penalty ramps up to 2 percent starting this October and grows to 3 percent the following year.


The penalties have not been popular with hospital executives, with many complaining that they are excessive and unfair to hospitals with large numbers of low-income patients, who tend to be readmitted more frequently. In an article this month in the New England Journal of Medicine, two Harvard professors who have been critical of the program, Drs. Karen Joynt and Ashish Jha, urged changes, writing that the program “will penalize hospitals that care for the sickest and the poorest Americans, largely because readmissions are driven by the severity of underlying illness and social instability at home.”

So far, the Centers for Medicare & Medicaid Services has declined to change the program. But the Medicare Payment Advisory Commission, an influential panel that reports to Congress, is looking at possible changes that would result in lower or no penalties for many hospitals. Those options include decreasing penalties if the hospital industry as a whole lowers readmissions, and taking the economic profile of a hospital’s patients into account when setting the penalties.

At a meeting last week, MedPAC commissioners expressed enthusiasm for backing some version of these changes. None of these changes, however, could be made unilaterally by Medicare; they would need to go through Congress, a politically dicey route considering the ongoing disagreement about the health care law.

The technical side of enacting the penalties has been just as complicated. Medicare originally released the penalties last August, but then revised them at the end of September after determining that it had left some patients out of its calculations. That change increased penalties for 1,422 hospitals and decreased them for 55 others. “Since that time, we have determined that these corrections still contained errors,” Medicare wrote in a correction note dated March 7 and posted on its website this week.

This second correction brings many hospitals closer to where they originally were. In fact, 329 hospitals that had their penalties altered in September are now having their initial penalties restored. But for some, life has gotten increasingly tougher: Magnolia Regional Medical Center in Magnolia, Ark., had initially seen its penalty rise from 0.92 percent to 0.98, and now to the maximum of 1 percent.

Three hospitals facing penalties no longer will: Kettering Medical Center in Kettering, Ohio; Providence Willamette Falls Medical Center in Oregon City, Ore.; and Community General Hospital in Dilley, Texas. All three had been facing the smallest possible penalty, a hundredth of a percent.

The total number of penalized hospitals is 2,213, roughly two-thirds of hospitals whose readmission rates were reviewed. The number of hospitals receiving the maximum 1 percent penalty decreased from 307 to 276.

Kaiser Health News had earlier published the penalties for all hospitals and has updated its printable PDF chart and downloadable CSV file with the corrected readmission penalties.

Health Law Bars Opting Out Of Maternity Coverage; Long Term Care Insurance Is Guaranteed If Company Goes Out Of Business

This week, I am answering readers' questions about maternity coverage requirements in the new health insurance exchanges, long-term-care insurance and switching employer health plans.

Q. Under the Affordable Care Act, will all plans have to cover maternity benefits in 2014? I do not want maternity coverage. Will I have the option to decline maternity coverage in an individual plan?


A. Maternity and newborn care are together considered one of the 10 "essential health benefits" that most individual and small-group plans sold on the state-based health insurance exchanges and the private market will be required to offer in 2014. (If the plans have grandfathered status under the law, they'll be exempt, however.) Declining coverage will not be an option.

This requirement will bring small-group and individual plans into line with the coverage that's already required under the Pregnancy Discrimination Act for companies with 15 or more workers, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and policy center on issues of sexual and reproductive health.

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"Not offering maternity coverage when you cover other types of care is sex discrimination," he says. "The Affordable Care Act is trying to close that loophole."

From a practical standpoint, there’s another consideration. Insurance is intended to protect people against the unexpected, explains Sonfield. Nearly half of all pregnancies are unintended, according to the federal Centers for Disease Control and Prevention.

"Pregnancy happens," he says. "They're not always planned."

Q. If I purchase a long-term-care insurance policy in my 60s and don't need to use it for another 10 or 20 years, what happens in the event that the company that I've contracted with goes out of business or changes corporate structure and assumes a different identity? Are there any states that have protections in place for cases like this?

A. Every state and the District have life and health insurance guaranty associations that protect consumers if they buy a long-term-care policy from an insurer that later fails. Funded by insurers that do business in a state, the associations ensure that coverage continues and benefits are provided even if an insurer is no longer in existence. The associations do this by either taking over the policies themselves or placing them with another, healthy insurer.

Insolvencies are uncommon but not unheard of, says Bonnie Burns, a policy specialist at California Health Advocates, a Medicare advocacy and education organization.

There is one potential wrinkle, however, she says. Although your coverage and benefits will continue if your insurer fails, each state caps the maximum amount that policies taken over by the guaranty association pay out, typically between $100,000 and $300,000.

It's much more common for insurers to change hands or sell their long-term-care insurance business than to shut down. If that happens, your coverage shouldn't be jeopardized.

"It doesn't affect the policy," Burns says. "That's a legally binding contract that's guaranteed under state law."

Q. My family and I are members of my employer's health insurance plan. We are considering opting out at the next available opportunity and switching to the plan offered by my spouse's employer. However, my employer has recently decided that soon employees will no longer be allowed to opt out and that all of those who opted out in the past will be recalled. Can they do that?

A. If both spouses have health insurance through their jobs, they can generally choose the plan that best meets their needs. Switching from one plan to the other is typically allowed, although there may be enrollment periods or other rules.

The experts I asked think that your employer's decision to soon disallow opting out may be a misreading of a provision of the health law.

Under the law, most people are required to have health insurance starting in 2014 or pay a penalty. A provision in the law requires employers with more than 200 employees to automatically enroll employees in a company health plan, although the government has announced it is pushing back implementation of that requirement. Employees can decline the coverage if they choose.

The provision applies to new full-time employees and to current employees who are enrolled in a company plan. Your employer appears to believe the law applies to any current employee, including those who may have opted out in the past.

That's not what the law says, according to J.D. Piro, a senior vice president at Aon Hewitt who leads the firm's health law consulting group.

"There's nothing in the law about recalling previous opt outs," he says.

Originally, the Department of Labor was to have issued rules about implementing automatic enrollment by 2014, but that process has been delayed, according to DOL.  The department says it "has concluded that its automatic enrollment guidance will not be ready to take effect by 2014."

Observation Units Can Improve Care But May Be Costly For Patients

There's a growing recognition by clinicians that some patients who arrive at the emergency department can benefit if they’re kept under observation for up to a day so that staff can run more tests and monitor their progress to see if their condition is improving or deteriorating.


Unfortunately, many hospitals and insurers haven't set up their clinical and billing systems or insurance contracts with these patients’ needs in mind. Not only does this result in a longer stay in some cases, but it also can cause confusion for patients and bigger patient bills. Many experts say that the problem is likely to get worse.

More than a third of hospitals report having an observation unit today, double the 19 percent that reported having one in 2003.

Experts say that the most effective observation units have a dedicated staff that follows clearly defined protocols. Rather than send a patient home who is at high risk for a heart attack following an emergency department visit because of chest pain, for example, staff might refer him to an observation unit for repeat blood tests, EKGs and a stress test. A patient with severe asthma who needs time and medication to get an attack under control might be sent to the observation unit for several hours.

By monitoring and treating patients intensively upfront, observation unit staff can forestall problems and help people get better faster. Patients typically stay less than a day, though some may remain longer.

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"These are patients who fall between the cracks," says Michael Ross, an emergency physician who is director of observational medicine at Emory University School of Medicine in Atlanta. "They need more than an emergency department visit, but if managed practically they often need less than 24 hours of care."

Shorter hospital stays can result in lower hospital costs. A study that Ross co-authored on emergency department patients who had had a transient ischemic attack -- a temporary interruption of blood flow to the brain that causes stroke-like symptoms and is sometimes a harbinger of a true stroke -- showed that those who were referred to an observation unit were discharged nearly 38 hours sooner than those who were admitted as inpatients. Observation unit patients also cost the hospital less: The median amount was $2,092 versus $4,922.

But hospital savings don't necessarily translate into lower costs for patients. Insurers treat care provided in an observation unit as outpatient care. That often means patients pay a la carte for every X-ray, blood test or scan. In contrast, if patients are admitted as inpatients, they may owe only a single co-payment, after which all or nearly all services are covered. And for Medicare patients, being assigned to observation care rather than inpatient care can bring higher drug bills and affect coverage of subsequent nursing home care.

Part of the problem is that many hospitals that place patients on observation status don't necessarily have a designated unit where such patients are treated. Instead, they may place emergency department patients on observation status and put them in a bed on one of the regular inpatient hospital floors. Such patients frequently don't receive the care based on clearly defined protocols shown to be successful in designated observation units, experts say. Adding to the confusion, the patient may think he's been admitted and not realize he's going to be billed for outpatient rather than inpatient care.

"It's a terribly inefficient way to provide observation services," Christopher Baugh, medical director of the emergency department observation unit at Brigham and Women's Hospital in Boston, says of care that isn't provided in a separate unit. "It's also difficult to communicate [the difference] to patients who are in an inpatient area and sharing a room with an inpatient and spending sometimes a long time there."

But the arrangement can be attractive to hospitals. Placing patients on observation status and putting them in a bed somewhere in the hospital reduces crowding in the emergency department. It may also reduce the number of admissions. The Centers for Medicare & Medicaid Services and private insurers are monitoring hospital admissions closely and have been retroactively denying payment if they determine an admission wasn't warranted.

"We're going to see an explosion in observation status," says Arthur Kellermann, a physician and senior researcher at Rand, a public policy research organization. Under the Affordable Care Act, hospitals with high readmission rates for Medicare patients with pneumonia, heart attack or heart failure are financially penalized.

The health law could prompt hospitals to use the observation designation with more patients, even if they don't receive special care, say experts.

Unfortunately, the "complexity of this fragmented, loophole-ridden payment system has taken one of the best ideas in medicine and made it confusing to patients and doctors," Kellermann says. "It could undermine what is one of the best ideas in health care."

New Coverage May Spur Younger Women To Use Long-Acting Contraceptives

Even though they're more effective at preventing pregnancy than most other forms of contraception, long-acting birth-control methods such as intrauterine devices and hormonal implants have been a tough sell for women, especially younger ones. But changes in health-care laws and the introduction of the first new IUD in 12 years may make these methods more attractive. Increased interest in the devices could benefit younger women because of their high rates of unintended pregnancy, according to experts in women's reproductive health.


IUDs and the hormonal implant -- a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years -- generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women's health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

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Long-acting reversible contraceptives (LARCs) require no effort once they're put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Across all age groups, nearly half of pregnancies are unintended, but younger women's rates are significantly higher, according to a 2011 study from the Guttmacher Institute, a reproductive health research organization. Eighty-two percent of pregnancies among 15- to 19-year-olds were unintended in 2006, and 64 percent of those among young women age 20 to 24 were unintended, the study found.

Although the use of LARCs has more than doubled in recent years, it is a small part of the contraceptive market. Among women who use birth control, 8.5 percent of women used one of those methods in 2009, according to the Guttmacher Institute. The use of LARCs by teenagers was significantly lower at 4.5 percent, while 8.3 percent of 20- to 24-year-olds chose this type of contraception.

In October, the American College of Obstetricians and Gynecologists reiterated its strong support for the use of LARCs in young women.

Yet many young women are unaware that long-acting methods could be good options for them, in part because their doctors may be reluctant to prescribe them, experts say. That is partly the legacy of the Dalkon Shield, an IUD that was introduced in the 1970s whose serious defects caused pain, bleeding, perforations in the uterus and sterility among some users. The problems led to litigation  that resulted in nearly $3 billion in payments to more than 200,000 women.

In addition, providers may hesitate because there's a slightly higher risk that younger women will expel the device, experts say.

But expulsion is a problem more likely associated with the size of the uterus, which is not necessarily related to a patient's age, says Tina Raine-Bennett, research director at the Women's Health Research Institute at Kaiser Permanente Northern California and chairwoman of the ACOG committee that released the revised opinion on LARCs. "Expulsion is only a problem if it goes unrecognized." (Kaiser Health News is not affiliated with Kaiser Permanente.)

The new IUD Skyla became available in mid-February. It is made by Bayer, the same company that makes Mirena, another IUD sold in the United States. Unlike Mirena, which is recommended for women who have had a child, Skyla has no such restrictions (nor does ParaGard, the third type of IUD sold here). Mirena is currently the subject of numerous lawsuits alleging some complications, such as device dislocation and expulsion.

Skyla is slightly smaller than the other two IUDs on the market and is designed to protect against pregnancy for up to three years, a shorter time frame than the others.

This shorter time frame may make Skyla more attractive to younger women who think they may want to get pregnant relatively soon, some experts say, although any IUD can be removed at any time.

"More providers are spreading the word that it's okay, and more young women are demanding it," says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.