Family physician, author, blogger, speaker, physician leader.

Published Op-eds

How to make your health insurance count as if your life depended on it

Davis Liu. Monday, November 1, 2004. San Francisco Chronicle

It’s that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the “perfect” Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention.

But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimates that this year, 79, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely –  not because of hospital errors, misdiagnoses or negligence, but because they chose the wrong insurance plan. Had they selected a high- quality program, the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association would have been reached and their lives prolonged.

When NCQA compared the performance of the top 10 percent of health plans with the national average on certain measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, it discovered variability among plans exceeding 20 percent. If one used similar criteria to compare the safety performance of the top 10 percent of airline carriers with the national average, the quality gap was far less than 1 percent. The same applied for banking and manufacturing. How safe would you feel about flying if among the various airlines there was a quality variance of more than 20 percent? Yet, when it comes to health care, consumers don’t appear to be concerned.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . This means you have an increased chance of not knowing whether you’re choosing a poor-quality health plan this year.

As if that weren’t enough, during this enrollment period, the term “consumer-driven health plans” is the new catchphrase for cost containment. In an effort to save money, employers are less likely to provide comprehensive coverage, but rather directly give you the dollars to manage and spend on health care. Now you, not the health-insurance plan, will decide what tests, treatments and procedures you can afford. For your nagging sciatica, should you pay for an MRI of the spine or a CT scan to rule out a herniated lumbar disc? For your sake, with the burden of financial responsibility and the lack of consistency among health plans, you’d better hope you never ever get ill.

So what can you do? Although there is no national urgency to fix the problem, you aren’t completely powerless. First, check out the NCQA Web site ( and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It’s your money. Don’t you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. How do I know? I am employed by one of the health plans highly rated by NCQA. My hope is that with hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.

Davis Liu is a full-time primary care physician who lives in Sacramento.

Originally Published Here:

Not all health plans are equal

Davis Liu. Wednesday, November 2, 2005. San Francisco Chronicle

Given an opportunity to select between good health and great health, which would you choose? I’m not referring to the daily decisions on what to eat or how much (or little) to stay healthy, but that dreaded choice we make every year during open enrollment for health insurance. Although selecting a health plan seems like a roll of the dice, we shouldn’t gamble with our health, particularly when reliable information is available.

Recently, the National Committee of Quality Assurance teamed with U.S. News & World Report in releasing the annual rankings for the best health plans in America. Not surprisingly, there are tangible differences in terms of quality and service among health plans regarding patient satisfaction with their physicians and care, childhood immunization rates, timely care for pregnant women, mammogram screening rates and the level of care provided to diabetic patients. Had all health plans performed as well as the nation’s best, NCQA estimates that last year, 83,000 deaths (twice the seating capacity of SBC Park) could have been prevented. The top-rated plans have programs, systems and incentives in place so that physicians can improve the health of the chronically ill and also those of us who are healthy but often too busy to remember do the preventive screening tests.

Although the report found that the overall quality of health plans has improved over the past six years, it identified some troubling trends. The majority of Americans still mainly rely on family and friends to choose health-care plans instead of using objective sources and report cards. This can be problematic. While 43 percent of Baby Boomers with parents age 65 or older say that their parents would turn to them or other friends and family for health insurance information, 43 percent also feel they know “next to nothing or nothing at all about health insurance to help their parent.”

In addition, there is little performance data on the more popular preferred-providers organization plans, because traditionally they have not been as accountable to state and federal agencies, or the media, as HMOs and point-of-service plans.

Finally, as more of us shoulder the costs of health insurance and new high-deductible health-care insurance options, do we truly understand what we are getting, or is it buyer beware?

What I found most troubling was a conversation I had with my sister-in-law. A recent Wharton graduate who had landed her first job, she selected her health plan based on the lowest premium, figuring that because she was young and healthy, she wouldn’t need to use it. She didn’t realize that her plan scored the worst among members and those trying to access medical care. With 1 in 10 Americans treated annually in emergency rooms for nonfatal injuries, there is a chance she will discover whether this was a good choice. The disturbing thing is that she, like many of us, assumes that all health plans are created equal.

This year, consider selecting your health plan the same way you purchase other goods and services, by doing some research and choosing wisely. Look to other sources of information to help you choose. Besides the NCQA report (, the California Office of the Patient Advocate provides quality-of-care report cards for medical groups and HMOs in California (check out Don’t be shocked if you discover that your medical group had “too few patients to report,” was “not willing to report” or chose not to report when it was evaluated on whether the right medical care was delivered.

Investing a few minutes of your time might prevent an unnecessary premature death. At a minimum, it could help you make the difference in whether you have good health and great health.

Originally Published Here:

Consumer, manage your medical savings account

Davis Liu. Friday, November 12, 2004. Sacramento Bee

Get ready for the rationing of health care in America.  It will fundamentally change the way we access health care.  But before writing a letter to your senator or calling your health insurer to complain, open your wallet and then take a good look in the mirror.  Getting the care we need and deserve will rely completely on our own ability to choose and spend wisely on medically necessary procedures and treatments.  We, not the government or the insurance companies, will be responsible for rationing our health care.

With escalating health care costs and no end in sight, the new catch phrase for cost containment is “consumer driven health plans.”  Companies save by purchasing less expensive and less comprehensive coverage, and with the extra money they set up health savings accounts (HSAs) and give us, not the insurance company, control of the funds to manage our own health care costs.

These accounts, strongly promoted by President Bush as reform, shift the financial risk completely to the consumer.  The thinking goes that when patients spend their own money on health care, they will become savvy consumers, decrease overuse and demand appropriate cost-effective treatments.  Already many consumers may have noticed more fiscal responsibility than in the past with rising deductibles, co-pays, and co-insurance cost sharing.

How prepared will we be to meet this new challenge?  Though as consumers we assess and purchase other goods and services daily, finding the relevant information for health care is not easy.  Research shows that Americans are not eager to switch to a system that makes them more accountable for their health care, but the economic reality is that employers cannot continue providing comprehensive health insurance.  A study by the Kaiser Family Foundation wonders if small employers (under 200 employees) will offer family coverage in the near future.  The government does not seem interested in truly reforming the health care system despite the glaring statistic that we spend more per capita than any other nation and yet cannot claim we live the longest.

And retirees aren’t immune either as employers are curtailing or dropping benefits entirely.  The mutual fund company Fidelity identifies health care costs as a major risk to retirement and estimates a couple retiring in 2004 needs $175,000 just to fund future out-of-pocket medical expenses.  For future retirees, the picture is bleak with predictions that health care costs will take up an amount equal to 20 percent of an earner’s pre-retirement income.

The next time your back aches and the sciatica flares up, you have to wonder, with your high-deductible insurance plan, what I can afford?  You can ignore the back pain and do nothing, see your primary care physician or seek care with a back specialist, a spine surgeon.

Either physician may recommend additional testing such as an X-ray, a CT scan or a MRI.  Since your insurance plan does not share the cost until your deductible is reached, did you save enough to pay for the doctors or any of these tests?  Your back pain could be a common low back strain or a slow growing cancer.

The challenges ahead are daunting.  What can you do?  Focus on prevention by exercising, quitting smoking and losing weight to stay healthy.  If you already have a diagnosis or problem, research the condition until you truly understand which treatments and options are appropriate.  Visit your doctor periodically to make sure you stay well.  Start saving money to cover your deductible so you never have to choose between your health and your finances.

Sadly, our health care system is shaping up to favor not the patients who need it most, but those with the knowledge and the finances to get medical care.  As a primary care physician, when I’m a patient, I’m ready for this new system.  Are you?  Welcome to rationing of U.S. health care in the 21st century.

The Best Health Insurance – Can Save Your Life

Davis Liu. October 30, 2010. Sacramento Bee

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy.


It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.