Autumn 2001

~ CANCER PREVENTION information inside ~~ CANCER PREVENTION information inside ~

F.A.Q. F.A.Q.ons frequently asked questions frequently asked questions frequently asked questions

quently asked questions frequently asked questions frequently asked questions frequen

... from our Health Advantage members

Q: How do I select a primary care physician (PCP)?A: When you enroll with Health Advantage, you will be provided a listing of primary care physicians fromwhich to choose. (You also may access our Web site at www.healthadvantage-hmo.com.) The listing willnote any restrictions based on age or other factors. You should list that PCP on your enrollment form. Pri-mary care physicians generally include general practitioners, family practitioners, internists and pediatricians.

Q: What is the age limit for dependent coverage?A: Dependent age limits are provided for the following:1. A child less than age 19 and living in the home.2. A child who is enrolled and regularly attending on-campus classes as a full-time student at an accredited

college, university or vocational training school, usually under age 21 and who is financially dependent onthe employee. (Check your Health Advantage Evidence of Coverage, as this age limit may vary.)

3. Refer to your Health Advantage Evidence of Coverage for additional dependent coverage.

Q: What should I do if my PCP is out of the office and I need immediate medical care?A: Your PCP’s contract requires him/her to have someone available to take calls 24 hours a day, seven days aweek. There should never be a time that you cannot reach your PCP or a covering physician who can directyou to the proper level of care.

Q: Does Health Advantage coordinate benefits?A: Yes. If you or your dependents have other insurance coverage, which provides benefits for hospital,medical or other expenses, your benefit payments may be subject to coordination of benefits. Even if HealthAdvantage is not the primary carrier, you still must follow the plan policies in order for Health Advantage tocoordinate benefits. It is the member’s responsibility to provide Health Advantage a copy of the primarycarrier’s Explanation of Benefits (EOB) and inform Health Advantage of all changes inother insurance coverage immediately.

Q: Will my new baby be covered as soon as it is born?A: A newborn is eligible for coverage from the date of birth, provided the child is enrolled within 90 days. Toavoid a delay in claims being paid, you should complete an enrollment form, have your group administratorsign it and submit it to Health Advantage as soon as possible. Your employer may require that this be donewithin 30 days, so we recommend that you check with your personnel office.

Q: If my PCP refers me to a specialist, should I verify with Health Advantage that this provider is in-network?A: Yes, it is a good idea to contact Health Advantage Customer Service or check the Health Advantage Website to verify that a specialist is participating with Health Advantage. As a member, it is your responsibility toensure that any provider that you see is participating.

3

is published four times a year by theArkansas Blue Cross and Blue ShieldAdvertising and CommunicationsDivision for the company’s mem-bers, health care professionals andother persons interested in healthcare and wellness.

Vice President of Advertising and CommunicationsPatrick O’Sullivan

EditorKelly Whitehorn — BNYou-Ed@arkbluecross.com

DesignerGio Bruno

ContributorsMark Carter, Janice Drennan, Damona Fisher and Kathy Luzietti

Customer Service Numbers

Little Rock Toll-freeCategory Number (501) Number

State/Public School Employees 378-2437 1-800-482-8416

e-mail: publicschoolemployees@arkbluecross.com stateemployees@arkbluecross.com

Medi-Pak (Medicare supplement) 378-3062 1-800-338-2312

Medicare (for beneficiaries only): Part A (hospital benefits) 378-3151 1-877-356-2368 Part B (physician benefits) 378-2320 1-800-482-5525

UniqueCare, UniqueCare Blue, Blue Select®, BlueCare PPO & PPO Plus (individual products) 378-2010 1-800-238-8379

Group Services 378-2070 1-800-421-1112

BlueCard® 378-2127 1-800-880-0918

Federal Employee Program (FEP) 378-2531 1-800-482-6655

Health Advantage 221-3733 1-800-843-1329

Medi-Pak HMO (Health Advantage) 954-5200 1-800-354-9904

USAble Administrators 378-3600 1-800-522-9878

For information about obtaining coverage, call:Little Rock Toll-free

Category Number (501) Number

Medi-Pak (Medicare supplement) 378-2937 1-800-392-2583

UniqueCare Blue, Blue Select®, BlueCare PPO & PPO Plus (individual products) 378-2937 1-800-392-2583

Regional Office locations:Central Little RockNortheast JonesboroNorthwest FayettevilleSouth Central Hot SpringsSoutheast Pine BluffSouthwest TexarkanaWest Central Fort Smith

Customers who live in these regions may contact the regionaloffices or call the appropriate toll-free telephone numbers above.

Web sites: www.arkansasbluecross.com,www.healthadvantage-hmo.com, www.BlueAnnEwe-ark.com

INSIDETHIS ISSUE

~Autumn 2001~

What is cancer?........................................... 4Depression & cancer, Cancer statistics ...... 5Watching for skin cancer............................. 6Reducing prostate cancer risk..................... 7Who’s at risk for breast cancer.................... 8Smoking: #1 cause of lung cancer ............... 9Cigarettes: the “cancer stick” .................... 9Lowering cancer risk: a doctor’s view ....... 10Focus on Health – Preventing Cancer ........ 11Why health care costs are so high ........ 12-13Pre-certification changed; Prenatal benefit .. 14Survey says – Health Advantage is A-OK .... 15Supporting JDRF ........................................ 15Group or individual health plan? ........... 16-17How coverage decisions are made ............ 18The pharmacist is in .................................. 19Race for the Cure; More member discounts ..... 19Financial information privacy notice ......... 20BlueAnn Club Update ................................. 21ASE/PSE customer info .............................. 22Women’s Health and Cancer Rights Act ..... 22Blue & Your Community ............................. 23Blue Online ................................................ 24

4 Cancer is the wordfor a group of more than 100 diseasesin which abnormal cells grow anddivide rapidly. These cells crowd outand destroy the normal ones. Theyalso can spread to other parts of thebody via the bloodstream andlymphatic system. This process isknown as metastasis.

Types of CancerAlthough cancer can begin in

almost any part of the body, thereare four basic types:

• Carcinomas: The most commontypes of cancers, which arisefrom cells that cover externaland internal body surfaces.Examples are lung, breast andcolon cancer;

• Sarcomas: Cancers arising fromcells found in the supportingtissues of the body, such asbone, cartilage, fat, connectivetissue and muscle;

• Lymphomas: Cancers thatoriginate in the lymph nodes andtissues of the body’s immunesystem;

• Leukemias: Cancers of theimmature blood cells that growin the bone marrow and tend toaccumulate in large numbers inthe bloodstream.

How Tumors FormNo one knows exactly why

cancer happens, but several causalfactors have been identified. Eachcell in the body has a specific

function. Normally cellsdo their job and

either divide toform new cells ordie. There is acontinuousbalance of newand dying cells in

normal tissue. In cancer, normalgrowth control is lost.

Sometimes a cell changes ormutates and doesn’t do the job itis supposed to do. Its DNA (geneticcode) is damaged. When thatcell divides, it makes moreabnormal cells.

The grouping of abnormal cellsin a specific area of the body iscalled a tumor. Some tumors arebenign, meaning that they do notspread. They can often be removedand, in most cases, they do not comeback. Those that spread are calledmalignant tumors. Only malignanttumors are considered cancerous.

Cancer spreads in two ways.Cancer cells can invade adjacenthealthy tissue by migration orpenetration, or the tumor cells canbreak away and travel to otherparts of the body, where they formnew tumors.

Tumor GradesFor most cancers, a biopsy,

which is the surgical removal of asample of the affected tissue, revealsinformation about the status of thecancer. The tissue is examined undera microscope and assigned a grade. Alow grade (I or II) refers to tumorswith fewer cell abnormalities. A highgrade (III or IV) indicates highlyabnormal cell appearance and largenumbers of dividing cells.

Cancer StagesTumors also are classified

according to the stage of the cancer.These stages are based on the size ofthe tumor and whether it has spread.In general, these stages are:I. A small, localized tumor;II. A larger tumor that is beginning

to spread into other organsand cavities;

III. Cancer cells have spread toregional lymph nodes;

IV. Cancer has metastasized to otherparts of the body, often tomultiple organs and tissues.

Causes of CancerCancer develops over time.

Cancer results from a complex mixof factors related to lifestyle, heredityand environment. Medicalresearchers have found substancesthat cause cells to mutate, includingchemicals, radiation, virusesand bacteria. By far, the largestexposure of humans to chemicalscomes from smoking.

Most cancers (80 to 90 percent)occur in people with no familyhistory of the disease. Some types ofcancer do occur more frequently infamilies. Whether that occurrence isbecause of lifestyle, environment orheredity is unknown.

Risk FactorsStudies over the years have

shown that certain risk factors areassociated with cancer, but noteveryone with these risk factors willdevelop cancer. In turn, not everyonewho has cancer has evidence ofthese risk factors. Risk factorsinclude: tobacco; diet (high-fat,possibly low-fiber); ultravioletradiation (from the sun and tanningbooths); alcohol (heavy drinking);ionizing radiation (from X-rays,atomic explosions, outer space,radioactive substances); chemicalsand other substances (i.e., pesticides,cigarette smoke, asbestos, uranium,benzene); hormone replacementtherapy (estrogen alone);diethylstilbestrol (DES) (syntheticestrogen); and heredity.

What is Cancer?

— Source: National Cancer Institute (For more information, visit http://www.nci.nih.gov.)

What is Cancer?

5• This year, more than 552,200 Ameri-

cans are expected to die of cancer,more than 1,500 people per day.

• Cancer is the second leading cause ofdeath in the U.S., exceeded only byheart disease.

• Skin cancers are more common thancancers of any other organ, and morethan 1.3 million cases of basal celland squamous cell cancer areexpected to be diagnosed this year.

• The five-year relative survivalrate for all cancers combined is60 percent.

• The National Institutes of Healthestimate overall costs for cancer inthe year 2000 were $180.2 billion:$60 billion for direct medical costs(total of all health expenditures);$15 billion for indirect morbiditycosts (cost of low productivity dueto illness); and, $105.2 billion forindirect mortality costs (cost oflost productivity due topremature death).

• Approximately 1,268,000 new cancercases are expected to be diagnosedin the U.S. in 2001.

• Anyone can get cancer. Most casesaffect adults beginning in middleage. Nearly 80 percent of all cancersare diagnosed at ages 55 and older.

• In the U.S., men have about a 1 in 2lifetime risk ofdevelopingcancer,and forwomentherisk isabout1 in 3.

A diagnosis of cancer is oftenunexpected and alarming, causingemotional upset and anxiety for theperson with cancer. More often thannot, the emotional turmoil subsideswithin a few weeks, but if it doesn’t,the patient should beevaluated fordepression.Depression occursin about 10percent of thegeneral adultpopulation, but itoccurs in approxi-mately 25 percent ofadults with cancer.

Symptoms include:• Persistent sad mood• Loss of interest in normal

activities• Fatigue or lack of energy• Inability to sleep or sleeping

too much• Loss of appetite or weight gain• Difficulty concentrating or

remembering• Feelings of guilt and

worthlessness• Thoughts of suicide or suicide

attempts

• Irritability or excessive crying• Chronic aches and pains that

don’t respond to treatment.Many times, depression in cancer

patients goes undiagnosed because itis thought to be a reaction to the

diagnosis.Treating cancerpatients withdepressionimproves themental condi-tion of thepatient, reducessuffering and

enhances thequality of life. Depression has beenshown to cause immune suppres-sion, which can affect the body’sability to fight cancerous cells.

Studies show that the moresevere the medical condition, themore likely the person will beclinically depressed. With treatment,80 percent of all depressed peoplecan improve, usually within weeks.Treatment options include medica-tion, psychotherapy or a combinationof both. If you think you may besuffering from depression, pleaseconsult your physician.

— Source: National Institute of Mental Health

Depression& CancerDepression& Cancer

Cancer statisticsCancer statistics

6 Mirror, mirror on the wall

The mirror is your best friend when it comes to detecting skin cancer

Skin cancer affects approximately the same numberof patients as all other cancers combined, according tothe American Cancer Society. In 2001 alone, there will bemore than 51,000 cases diagnosed in the United States.

Early detection and treatment are crucial. The mostcommon types of skin cancer, squamouscell and basalcell carcinoma,are curablewhen detectedearly. Mela-noma skincancer is moreserious becauseit often spreadsto other parts ofthe body.

Squamous celland basal cellcarcinoma —nonmelanomaskin cancer

Approximately75 percent of allskin cancers arebasal cell carcinomas.They usually are found on areas exposed to the sun suchas the head and neck. It is a slow-growing cancer, and itis unusual for it to spread to other parts of the body.

Squamous cell carcinoma accounts for approximately20 percent of all cancers. They usually appear on theface, ear, neck, lips and backs of hands (areas exposed tothe sun). Very few squamous cell skin cancers spread toother parts of the body.

Melanoma skin cancerMelanoma skin cancer is mostoften seen on the torso of fair-

skinned men and on the lowerlegs of fair-skinned women.Having dark-pigmented skinlowers the risk of mela-noma, but it does not meanthat a person with dark skincannot get melanoma.

Risk factors for mela-

noma skin cancer include:• Moles — A mole is a benign

skin tumor. Moles are notusually present at birth but begin to appear in childrenand teenagers. Having certain types of moles (suchas dysplastic nevus or an atypical mole) increasesthe risk for melanoma. They are often larger thanother moles.

• Fair skin — Caucasians with red or blond hair andfair skin that freckles or burns easily are at an espe-cially high risk for melanoma cancer.

• Family history — The risk is greater if a close relative(mother, father, sibling or child) have been diagnosedwith melanoma.

• Immune suppression — People who have been treatedwith medicines that suppress the immune system,such as organ transplant patients, have an increasedrisk of developing melanoma.

• Too much sun — People with too much exposure tolight from the sun or tanning beds and lamps, are at agreater risk.

• Age — Approximately 50 percent of melanomas occurin people age 50 and older. However, melanoma is themost common cancer in people age 30 and younger.

Melanoma skin cancer can be detected early; andyou, along with your physician, play an important role indetection. Part of a routine checkup should include askin examination. It’s also important to check your ownskin about once a month. You should know the patternof moles, freckles and other marks on your skin so youwill notice any changes. Self-examination is best done infront of a full-length mirror. A hand-held mirror may beused for areas that are hard to see.

Spots on the skin that change in size, color or shapeshould be seen by a physician right away. Following arethe differences between normal moles and melanoma.Watch for signs of possible melanoma.• One half of the mole does not match the other.• Edges of the mole are ragged or notched.• Color of the mole is not the same all over.• The mole is wider than about 1/4 inch.

After melanoma is found, your physician will deter-mine what treatment plan is best for you. Treatmentoptions may include surgery, chemotherapy and radiationtherapy. If you have questions about melanoma,please consult your physician.

7Prostate cancer has a specific target — men over the age of 40. While it remains

rare for men under 50 to contract the disease, almost half of American men under 70have at least microscopic prostate tumors, studies reveal.

By the time a man reaches his 80s, that percentage rises to 70 to 90 percent. So,chances are most men will have to deal with prostate cancer in one form or another.The lifetime probability for contracting prostate cancer for an American man is 8percent. But prostate cancer is a slow-developing disease and, if detected early, ismanageable and even curable.

Prostate cancer is the most common form of cancer contracted in American men, inwhom it is the second leading cause of cancer death, behind lung cancer.

Prostate cancer is a malignant tumor that develops in the prostate gland (found inmen only) that can spread through the blood and lymph fluid to other organs, bonesand tissues. Compared to other cancers, prostate cancer is slow-growing — as many as90 percent of all prostate cancers remain dormant and not clinically important fordecades. Symptoms usually are not noticeable in early stages of the disease, whichmakes early screening via a physician’s examinationall the more important. But once symptoms dooccur, they include a slowing or weakening of theurinary stream, frequent urination, blood in theurine, swollen lymph nodes in the groin area,impotence, and/or pain in the hips, ribs, pelvisor spine.

Early detection and more accurate screeningtests have led to a decrease in the number ofdiagnosed cases in recent years. Men with a historyof the disease in their family should be aware thatgenetics plays a significant role in the developmentof the disease. The risk for prostate cancer also hasbeen found to be greater in men whose mother orsister had breast or ovarian cancer.

Lifestyle factors such as diet and exercise havebeen found to reduce the risks of contracting prostate cancer.

Treatment for prostate cancer today is highly successful and includes surgery toremove the prostate gland, radiation, various medications that slow the growth of thecancerous cells, and sometimes chemotherapy.

The important thing is to be aware of the risk factors and to remember that thesymptoms don’t have to obvious for prostate cancer to exist. Regular exams with yourpersonal doctor are the key to early detection and prevention. Your doctor can test yourprostate-specific antigen (PSA) levels to determine if the prostate isenlarged due to infection or cancer.

For more information on prostate cancer, its causes, associatedrisks, symptoms and treatment, visit the American Cancer Societyon-line at www.cancer.org or WebMD at www.WebMD.com.

— Sources: WebMD and the American Cancer Society

Live Long and Prostate:Reducing your chances of cancer

8Breast cancer is not fruit from the family tree. In

other words, a family history of the disease is no guaran-tee a person will or will not develop breast cancer. Thecauses of breast cancer are not fully known, however,health and medical researchers have identified a numberof risk factors that increase a woman’s chances of gettingbreast cancer. Risk factors are not necessarily causes ofbreast cancer but are associated with an increased risk ofgetting breast cancer.

It is important to note that some women have manyrisk factors, but never get breast cancer. Some womenhave few or no risk factors but do get the disease.

Being a woman is the number-one risk factor forbreast cancer. Getting older is a risk factor that runs aclose second.

There are some risk factors that can be controlledand others that cannot. Remember, even if these riskfactors are not present, you still can develop breastcancer. Factors that may increase your risk of breastcancer include:

Factors you can control• Having more than one drink of alcohol per day.• Taking birth control pills for five years or longer can

slightly increase your risk for breast cancer.• Not getting regular exercise.• Currently or recently using some forms of hormone

replace-menttherapy(HRT) for10 years orlonger,which mayslightly increase risk.

• Being overweight or gaining weight as an adult.• Being exposed to a large amount of radiation, such

as having very frequent spine X-raysduring scoliosis treatment.

Breast Cancer ResourcesTo find out more about breast health or breast

cancer, check out the following organizations:

Susan G. Komen Breast Cancer Foundation1-800-462-9273www.komen.org

American Cancer Society1-800-227-2345www.cancer.org

National Cancer Institute1-800-422-6237www.cis.nci.nih.gov

Any Arkansas public library — books, video andaudio tapes have been made available for check-out atmore than 200 Arkansas public libraries by the KomenFoundation.

Factors you cannot control• Getting older — the older you get, the greater your

risk of breast cancer.• Having a mother, daughter or sister who has had

breast cancer.• Having the mutated breast cancer genes BRCA1 or

BRCA2.• Having had breast cancer.• Being young (<12 years) at the time of your first

period, starting menopause later (>55), never beingpregnant, or having your first child after age 30.

— Sources: Susan G. Komen Breast Cancer Foundation,National Cancer Institute

Breast Cancer:

Who’s at risk?

Breast Cancer:

Who’s at risk?

��

9More people die of lung cancer than of colon, breast

and prostate cancers combined. It is the number-onecause of cancer death for both men and women. It ismost often found in people 40 and older.

And there’s no doubt about it. Smoking cigarettes isthe leading risk factor for cancer. Researchers estimatethat smoking causes 8 out of 10 lung cancers. The morecigarettes smoked and the higher thenumber of years a person has smoked,the greater the risk for lung cancer.If you are a non-smoker butbreathe the smoke of others, youhave a greater risk of developinglung cancer. For example, if yourhusband smokes, you have a 30percent greater chance ofdeveloping lung cancer than aspouse of a non-smoker.

Smoking cigars or pipe does not help. They arealmost as likely to cause lung cancer as cigarette smok-ing. Also, smoking low-tar cigarettes does not reduce

your risk for lung cancer.Are there other risk factors besides smoking for lung

cancer? Yes. For example:• Working with asbestos;• Lung-scarring from some types of pneumonia;• Previous history of lung cancer;• Age.

However, sometimes people get lung cancer whohave never smoked and have no known risk factors.Researchers do not know why this happens; and, at thistime, it can not be explained.

Signs and symptoms of lung cancer include: acough that won’t go away; chest pain; hoarseness;weight loss and loss of appetite; bloody or rust-colored spit or phlegm; shortness of breath; feverwithout a known cause; recurring infections such asbronchitis; and wheezing.

Treatments for lung cancer include surgery,chemotherapy and radiation therapy. If you haveany questions about lung cancer, please consultyour physician.

Suppose that on each day of your life, on the newsevery single night, the lead story was that three — notone, but three — passenger jet airplanes had crashed,killing all aboard?

The news would be overwhelming and heartbreak-ing. Now imagine that it wasn’t an airplane crash thatkilled all those people, but cigarettes. The truth is thatyou don’t have to imagine that cigarette smoking kills alarge number of people each day because it is a reality.And the hardest reality to accept is that smoking is thenumber-one preventable cause of death.

Smoking causes lung cancer and is a risk factor forother types of cancer including mouth, larynx, bladder,kidney, pancreas, cervix, stomach and even leukemia. Tobacco smoke contains at least 43 carcinogenic(cancer-causing) substances. Tobacco use accountsfor one in every three of all cancer deaths in the UnitedStates. It is responsible for 90 percent of lung cancersamong men, and 70 percent among women. Approxi-mately 180,000 Americans die each year from cardio-

vascular disease caused by smoking.If you quit smoking, the benefits are immediate.

20 minutes after quitting — Blood pressure drops.8 hours after quitting — Carbon monoxide level inblood drops to normal.24 hours after quitting — Risk of heart attack decreases.2 weeks to 3 months after quitting — Circulationimproves; lung function increases.1 to 9 months after quitting — Coughing, sinus conges-tion and shortness of breath decrease.1 year after quitting — Excess risk of heart disease ishalf that of a smoker’s.5-15 years after quitting — Stroke risk is reduced to thatof a non-smoker.10 years after quitting — Lung cancer death ratedecreases to almost half that of a continuing smoker’s;risk of developing cancer of the mouth, throat, esopha-gus, bladder, kidney and pancreas decreases.15 years after quitting — Risk of coronary heart diseaseis that of a non-smoker’s.

It’s called “the cancer stick” for a reason

Smoking takes your breath away It’s the No. 1 cause of lung cancer

Smoking takes your breath away It’s the No. 1 cause of lung cancer����������

10

Little RockOncologistBill Tranumoffers somehelpful advice

Cancer

risk:

Can youlower

yours?

Cancer

risk:

Can youlower

yours?

Eat right. Exercise.

Don’t smoke. You hear that advice over and over again … on television, in magazinesand from your doctor. Following

a healthy regimen decreases yourrisk for illness and increases energy and quality of life.

So, does that advice work when it comes to helpingthe people of Arkansas lower their risk of developingcancer? Yes, according to Bill Tranum, M.D., a Little Rockoncologist with the Arkansas Oncology Clinic, P.A.

“It’s boring and it’s not what people want to hear.It’s public health, which means what the public can dofor themselves without a doctor. Don’tsmoke. Eat right. Maintain a healthyweight. Exercise. Avoid the sun. All ofthese would have immensely moreeffect than anything else, but this advicetakes time and it is boring to mostpeople,” said Dr. Tranum. ”There’s nomiracle, and all the herbs and vitaminsout there won’t help as much as justliving healthy.”

Arkansas Blue Cross and BlueShield and its family of companies havemany outstanding oncologists as part ofour physician networks. Recently, weinterviewed one of those physicians, Dr.Tranum (who is certified in both hema-tology and oncology by the AmericanBoard of Internal Medicine) to hear hispersonal thoughts on cancer preventionand other related issues.

As an oncologist, most of Dr. Tranum’s patientsusually have a suspicion, if not a diagnosis, of cancerbefore they enter his office. Most of his patients arereferred to him by family practice physicians or surgeonswho have discovered cancer through a biopsy. What hesees in his patients follows the national trend — amajority of his patients have been diagnosed withlung cancer.

“There’s not even a close second. Many of mypatients have been diagnosed with

lung cancer, usually caused bysmoking,” said Dr. Tranum.

After Dr. Tranum’s initialevaluation of his patients,he visits with them torecommend a treatmentplan. “The first thing I do iseducate them about the type

of cancer they have. I tell them what they have and whatstage the cancer is in. I then tell them the best treatmentoptions for them and the probability of cure,” saidDr. Tranum.

With his patients, he chooses to focus on the treat-ment plan and how to overcome their cancer. He doesn’tlike the negative aspects of cancer, and he is amazed atthe unfeeling behavior of family members at times.Sometimes people forget that cancer is not an automaticdeath sentence.

“They want to know how long the cancer patient hasto live. I am shocked by the insensitivity to ask this infront of the patient, and I won’t answer that question.

If the patient wants to know, I willdiscuss it. However, I like to focus onthe probability for survival,” saidDr. Tranum.

It’s not surprising that most patientsare nervous or upset to discover theyhave cancer, Dr. Tranum pointed out.However, he feels they are nervousbecause they do not know what toexpect. After he has the opportunity toexplain their cancer to them and putforth a timeline for treatment, patientsusually become less apprehensive abouttheir diagnosis.

During his 23 years as a privatepractice physician, there have beenmany advances in treatment options forcancer patients. Dr. Tranum notes thosehe considers his top three advance-ments in cancer treatment as:

1) Development of new medications.2) Statistical analysis of the effect of treatment

options.3) The control of nausea and vomiting (brought on

by treatment) for the patient.“We are just beginning to see strides with cancer.

We need more help in developing cures and treatmentoptions. People still die from cancer every day,” saidDr. Tranum.

While there is no definite cure for cancer and nocomplete assurance that a person will never develop it,there are very successful treatment plans that put cancerin remission and extend life for decades. And there’s nosubstitute for taking good care of yourself to reduce yourchances of developing cancer. Many, many people livelong, prosperous quality lives after a cancer diagnosis.

P reventing Cancer 11Testicular canceris curable

The most common type of cancerin men between the ages of 18 and 34is testicular cancer. However, whendetected early, it also is one of theeasiest to cure.

If testicular cancer goes undetec-ted at its earliest stages, it may spreadthroughout the lymph node systeminto the lungs and other parts of thebody. Testicular cancer is particularlydangerous because there are usuallyno symptoms associated with it.However, several predisposing factorsmay place some men at higher risk:past medical history of undescendedtesticle, mumps orchitis, inguinalhernia during childhood, or previoustesticular cancer.

All men should perform monthlytesticular self-examinations (TSE).The optimal time to perform theexamination is in the shower. Bothhands should be used to examineeach testicle with the thumbs in frontand the first two fingers behind thetesticle. The testicle should be rolledbetween the fingers and the thumb,feeling for any lumps or bumps.

Testicular cancer usually starts asa small pea-sized lump within thetesticle. It probably would not benoticed unless self-exams are rou-tinely performed. And, finding alump is no reason to panic (lumps orbumps in the testicle are not alwayscancer), but it is a reason to see yourphysician for an examination. Treat-ment of testicular cancer includessurgery (removal of the testicle andassociated lymph nodes), radiationtherapy and chemotherapy.

What you shouldknow about colonand rectal cancer

Colon and rectal cancer orcolorectal cancer begins in either thecolon or rectum. The colon has foursections, and cancer can start in anyof the four sections. Since colon andrectal cancer share many of the samefeatures, they are usually discussedtogether.

While researchers do not knowthe exact cause of colorectal cancer,risk factors include: family or per-sonal history of colorectal cancer;personal history of polyps or inflam-matory bowel disease; aging; diet andobesity; and lack of exercise.

Symptoms include: a change inbowel habits such as diarrhea orconstipation; a feeling that you needto have a bowel movement thatdoesn’t go away; bleeding from therectum or blood in the stool; crampingor steady stomach pain; decreasedappetite; weakness or fatigue; andjaundice (yellow-green color of theskin and in the white part of the eye).

Screening tests include a sigmoi-doscopy (a slender tube is placed inthe rectum to allow the doctor to lookat the inside of the rectum and part ofthe colon for cancer or polyps) and afecal blood occult test (sample of thestool is tested for blood). HealthAdvantage recommends that adultsage 50 and above receive a sigmoidos-copy every four years. Health Advan-tage also recommends that those 50and above have a fecal blood occulttest annually. The treatment ofcolorectal cancer includes surgery,radiation therapy and chemotherapy.

Information aboutHodgkin’s Disease

Hodgkin’s Disease (also knownas Hodgkin’s lymphoma) is cancerthat begins in lymphatic tissue —which includes the lymph nodes andother organs that are part of thebody’s system that forms blood andprotects against germs. Becauselymphatic tissue is found throughoutthe body, Hodgkin’s Disease can startalmost anywhere. If it spreadsthrough the lymphatic vessels andinto the blood stream, it may thenspread to almost any other place inthe body.

Both children and adults may getHodgkin’s Disease but it is mostcommon in two groups: early adult-hood (ages 15-40) and late adulthood(after age 55).

For the most part, there are nomajor risk factors for Hodgkin’sDisease. Some people with thedisease may have no symptoms.Others may have symptoms such asenlarged lymph nodes, coughing orshortness of breath, fever, nightsweats, itching, fatigue and loss ofappetite. Treatment for the diseaseusually is effective and includeschemotherapy and radiation therapy.

12As a physician in Arkansas, I’m acutely aware of

the rapidly rising cost of health care. And you, as aperson with health insurance, no doubt are feeling thedirect effects of these rising costs.

When the cost of medical care goes up, so does thecost of health insurance. But why is this happening?What is causing medical costs to rise rapidly, which inturn causes the cost of health insurance to increase?

Here are 12 major drivers of higher health care costsin Arkansas:

Changing Demographics — As a nation, our workforce is getting older. As we age, we consume a greateramount of health care. In Arkansas, our median ageincreased from 33.8 years in 1990 to 36.0 years in 2000,both of which are higher than the national average.

New Technologies — Today we are able to provideincredible new treatments such as organ transplants,which were not available just a few years ago. Whilethese advances have improved our quality of life, theyhave come at significant costs. Take the example ofpharmaceutical advances. In 2000, a new drug wasapproved for people with rheumatoid arthritis. Someexperts now believe that this drug should be used foralmost everyone with this illness. It improves the qualityof life for many people with this crippling disease.However, this drug costs $1,000 per month. To providethis drug for the approximately 4,800 of our insuredmembers who may need it, would result in a 6 percentpremium increase for all 480,000 members who are fullyinsured through Arkansas Blue Cross and Blue Shieldand Health Advantage. That’s right — one drug for1 percent of our members could raise premiums by6 percent for everyone. And … there are several other$1,000-per-month drugs for other illnesses available orin development.

Patient Demand — Americans are heavy consumers ofmedical services and demand choices in health care.They want access to heavily advertised drugs andservices and want more choice of providers.

Increasing Litigation/Regulations — Both the federaland state governments periodically develop new rulesand regulations that apply to insurers. Each of thesemandates results in premium increases. In addition, fear

of litigation has caused many ofthe restrictions of managed careto be lifted in the past fewyears. With the reduction inthese cost-containment effortshave come increases in medicalservices and costs.

Increasing Supply of Physicians — During the past 10years, the number of physicians has grown at a rate thatis 28 percent higher than the overall population. Studiesshow that as the supply of physicians increases, so doesthe number of services people receive from physicians.People see doctors more frequently for more minorproblems today than ever before. (While the number ofphysicians is increasing nationally, there is still anunequal distribution of physicians, with many rural areashaving too few physicians and many urban areas havingtoo many.)

Shortage of Non-Physician Professionals — Arkansasand the nation are experiencing a shortage of nurses.This is causing hospitals to compete for these health careprofessionals with higher salaries, thus driving upemployment costs. There is a similar, but less acute,shortage of physical therapy and occupational therapyhealth care professionals.

The Consumer Is Not the Direct Payer for Health Care— Few people realize that the drug for which they paid a$15 or $20 co-payment actually costs $150 or more.People are not aware that the few minutes they spendseeing a doctor for a common cold results in an averagetotal cost of $200 or more (doctor’s fees, lab/X-rays,pharmacy). Co-payments and deductibles have not keptup with medical cost inflation, making the consumer lessaware of actual costs. While most forms of property and

Information in this article was compiled and provided byRaymond Bredfeldt, M.D., medical director for ArkansasBlue Cross and Blue Shield’s Northwest Region, headquar-tered in Fayetteville. Dr. Bredfeldt is a board-certified familypractice physician. He served for10 years as director of the UAMS-AHEC Family Practice ResidencyProgram at Fayetteville.

Why Are Health Care12 Factors Driving Up

13casualty insurance cover catastrophic events (floods,fires, accidents), health insurance generally covers manycommon, everyday medical services, in addition tocatastrophic services.

Health Status of the Population — The health status ofthe Arkansas population is poor, ranking 46th in thenation. We have high rates of obesity, smoking, cancerand heart disease.

Emerging Diseases — The emergence of new diseases,or re-emergence of old, such as AIDS, Hepatitis C andtuberculosis, are driving up medical costs, as are suchfactors as environmental pollution and resistance toantibiotics.

Increasing Number of Uninsured — As health insur-ance premiums increase, so does the number of peoplewho decide to drop their insurance. This raises costs intwo ways. First, the people most likely to drop theirinsurance tend to be those who are healthy and believethat they can get along without insurance. As healthypeople leave the insurance pool, the people left withinsurance tend to be those with more health problems.This causes overall premiums to increase for those leftbehind in the insurance pool. Second, uninsured peopletend to utilize higher-cost care in emergency rooms forroutine problems since emergency rooms cannot turnanyone away. Often these services go unpaid. This raisesthe cost of health care for everyone else, because thesecosts are passed on to others.

Variability in Physician Practice Patterns — No twodoctors handle the same problems exactly alike. Forexample, in Arkansas the average cost to treat a commoncold in 1999 was $178 (it is closer to $225 in 2001). Onedoctor averaged $728 for every person he saw with acold in 1999. He ordered much more lab than the averagephysician. Similar degrees of variability occur with everytype of illness. There is probably no other industry inwhich that kind of variability exists in the delivery ofa service.

Excess Use of Avoidable Care — People tend to go todoctors for more minor problems today than they did 10years ago. They also get many more medical services.People have assumed that more is always better in regard

Did You Know?With rising medical costs causing health insur-

ance premiums to increase, it’s important to under-stand that Arkansas Blue Cross and Blue Shield is anot-for-profit, mutual insurance company.

That means that we are owned by our policy-holders, not by stockholders. All revenues earned byArkansas Blue Cross are utilized in only two ways: — To pay providers and members for coveredbenefits; — To pay associated administrative expense.

Any revenues received that are greater than thesetwo categories of expense are held as unassignedfunds (surplus) for future payment of claims andexpenses for the benefit of our members.

Health insurance is historically a cyclical busi-ness, and in those years when claims and expensesexceed revenues, surplus is used to meet thoseobligations to our members.

And while Arkansas Blue Cross is not-for-profit,it is not exempt from taxes. The company pays statepremium and federal income taxes like any otherhealth insurer. In 2000, this tax liability amounted tomore than $7.6 million.

Another important point is that Arkansas BlueCross is better able to serve its members because itmaintains low operating costs. In 2000, our adminis-trative costs were approximately 12.5 percent ofpremiums, which is lower than the industry average.This means that more than 87 cents of every pre-mium dollar in 2000 was used to pay for actualmedical care received by our members.

Costs So High?Medical Costs in Arkansas

to medical treatment. For example, it has been estimatedby the American Academy of Family Physicians thatAmericans receive 50 million unnecessary prescriptionsevery year for antibiotics. These unnecessary prescrip-tions cause side effects and are the reason that so manybacteria now are resistant to antibiotics.

14Beginning Aug. 13, 2001, Arkansas Blue Cross and

Blue Shield eliminated hospital admission pre-certifica-tion requirements for members who have insurancewith Arkansas Blue Cross and Blue Shield and HealthAdvantage HMO.

What does thismean for you as amember covered byHealth AdvantageHMO or ArkansasBlue Cross? Itmeans that you oryour physician areno longer requiredto call for pre-certification (orapproval) when youare admitted to an in-network hospital. Your physicianwill continue to make all decisions regarding youradmission and stay in the hospital. Admission pre-certification will no longer be required for routinehospital admissions, which includes hospitalization,surgery and diagnostic testing performed at in-networkfacilities. However, if services are performed at an out-of-network facility or outside the state of Arkansas, it willcontinue to be your responsibility to notify our utilizationmanagement company by calling the pre-certificationnumber on your ID card.

Hospital admission pre-certification will continueto be required for members in the following group

insurance plans:• Federal Employee Program (FEP) — ID cards feature a

number that begins with an “R”• Access Only — ID cards feature a toll-free telephone

number for pre-certification and Arkansas’ FirstSourcelogo (not an Arkansas Blue Cross and BlueShield logo)• USAble Administrators — All USAble mem-

bers with a pre-certification number notedon their ID card should be pre-certified priorto an admission.

“This change will reduce the administra-tive burden on members, physicians andhospitals. Yet at the same time, through acooperative arrangement with our hospitals,we will have the ability to monitor and offercase management services and care coordina-

tion,” said Mike Brown, vicepresident of EnterpriseMedical ManagementProgram and Policy. “It isour plan to continue todevelop a more streamlinedand simplified approach aswe work to improve ourmedical management and bring greater value to ourmembers.”

Should you have questions regarding yourhospitalization, you may contact your local ArkansasBlue Cross office.

Administrative burden eased for physicians, hospitals and members

Hospital admission pre-certification no longer required

Prenatal benefit amended for some groupsPrenatal benefit amended for some groupsFor members of a group (employer-sponsored)

health plan with an Arkansas’ FirstSource PPO policy ora comprehensive major medical policy from ArkansasBlue Cross and Blue Shield, the Routine Prenatal Carebenefit has been amended, effective Oct. 1, 2001.

The amended portion of the policy (OTHER COVERED

MEDICAL SERVICES, paragraph D), now states that, subjectto the applicable deductible and coinsurance, the Com-pany (Arkansas’ FirstSource or Arkansas Blue Cross) willpay for routine prenatal care, maternity care, obstetricalcare and complications of pregnancy. Previously, prenatalservices were paid at 100 percent. For any pregnancybeginning after Oct. 1, routine prenatal care services willbe paid at the same level as all other covered benefits ofthe policy, subject to the applicable deductible and co-

payment of that policy. For purposes of claims adminis-tration, this means that if a member delivers anytime onor before July 1, 2002, prenatal care services will be paidat 100 percent. If a member delivers on July 2, 2002 orafter, prenatal benefits will be paid at the same level asother covered benefits.

Bringing the prenatal benefit in line with all otherbenefits of the policy will help simplify the benefitadministration process, reducing errors and speeding upthe claims payment process, and ultimately help holddown costs to insured members.

The amendment does not affect individual policieswith Arkansas Blue Cross, nor does it affect HMO or POSpolicies with Health Advantage.

Members give Health Advantage a thumbs up!15Health Advantage fared well with its commercial

HMO population according to the results of the 2001Health Plan Employer Data Information Set (HEDIS)member satisfaction survey.

Those members responding to the survey gaveHealth Advantageexcellent ratings —virtually unchanged fromlast year — in severalcategories, includingrating of personal doctor,rating of specialist, ratingof all health care ser-vices, and rating ofhealth plan.

Health Advantage’s health care services and healthplans in general received high satisfaction marks, almostidentical to 2000’s results. The percentage of memberssatisfied with all health care services at Health Advan-tage came in at 94 percent (a rating of six or higher on a10-point scale). Sixty-two percent of members indicated asatisfaction rate of eight or higher with their health plan(88 percent rated their plan six or higher), up from 60percent last year and 57 percent in 1999.

The survey also revealed results similar to 2000:• Only 3 percent of members were not satisfied that

their claims were handled in a reasonable time.• Less than 1 percent were not satisfied that their claims

were handled correctly.• Only 3 percent reported a big problem in getting the

care the member or doctor felt was necessary or ingetting approval from the health plan.*

• More than nine out of 10 health care providers wereperceived by survey respondents to usually or alwayslisten carefully to patients, explain things in a way thepatient could understand, and show respect for whatthe patient had to say.

• Just under nine out of 10 providers were reported tousually or always spend enough time with theirpatients.

Based upon additional analysis of the survey results,the following service factors were determined to be thebiggest predictors and drivers of members’ overallsatisfaction with the health plan:• Claims processed in a reasonable time.• Claims handled correctly.• Understanding the Explanation of Benefits (EOB).

* We’d like to remind all Health Advantage members thatthe Health Advantage referral system is probably one ofthe most simple and “hassle-free” in all of the HMOindustry. Health Advantage does not require a “Mother-May-I” call to Health Advantage from Health Advantagemembers as long as the referral is for an in-networkprovider. A “referral script” is completed by the primarycare physician in his or her office, and it is given to themember, who then takes it to the specialist. All thespecialist has to do is make sure he or she gets the“referral script” from the primary care physician and usesthe number on the script pad for filing the claims.

Members give Health Advantage a thumbs up!

As a good corporate citizen, Arkansas Blue Crossand Blue Shield employees participate in manycommunity activities around the state in an effort to raisemoney for causes important to our members.

One of those causes is the Juvenile DiabetesResearch Foundation (JDRF). This year, ArkansasBlue Cross served as the title sponsor of theannual JDRF Walk to Cure Diabetes held onSaturday, Sept. 22. Sharon Allen, executive vicepresident and chief operating officer for ArkansasBlue Cross, served as the 2001 walk’s corporaterecruitment chairperson.

More than 16 million Americans (about 5 millionundiagnosed) suffer from diabetes, a chronic, debilitatingdisease that affects every organ system in the body.

Someone dies from those debilitating effects everythree minutes, and diabetes is the leading causeof kidney failure, adult blindness, and non-traumatic amputations, and is a leading causeof nerve damage, heart attack and stroke. TheU.S. spends $105 billion each year in diabetes-related costs.

For more information on diabetes, visit theJDRF Web site at www.jdrf.org.

Supporting efforts to find a cure for DIABETESDIABETES

16If you are considering leaving your job in

the corporate world to become self-employed …not so fast. Before you quit your job, think aboutyour health insurance options. While you wereaccepted into your employer’s group healthinsurance plan with no hesitation, it might notbe so easy when you are out on your ownlooking for individual health insurance.

Individual health insuranceThe most important thing to remember is

that you enroll in a group insurance plan withyour employer (you cannot be excluded), butyou apply for individual health insurance. Thetwo insurance options are unrelated; and whenyou leave the protection of your group insuranceplan, you are starting from the beginning in yoursearch for health coverage.

Being enrolled in an Arkansas Blue Crossand Blue Shield group insurance plan does notguarantee that your application for individualhealth insurance will be approved. ArkansasBlue Cross members may be eligible for aCOBRA and/or a Conversion policy. This is notthe same as individual health insurance asdiscussed in this article.

Additionally, being in one of Arkansas BlueCross’ individual health insurance plans does notguarantee acceptance into another. To changeplans, you must go through medical underwrit-ing and start the whole process again — there isno transfer of credit toward meeting deductiblesor pre-existing periods.

“Individual business does not take intoaccount previous health insurance coverage. Ifyou apply for individual coverage, it doesn’tmatter if you were on another Arkansas BlueCross individual health plan or moved here fromthe woodlands of Canada, you are starting fromscratch,” said Ron DeBerry, vice president ofStatewide and Individual Business.

Applicants for individual health insuranceplans (Blue Select®, BlueCare PPO and BlueCarePPO Plus) at Arkansas Blue Cross are subject tothe following:1) Medical underwriting (which is the process

of evaluating and assuming risks accordingto your insurability).

2) A 12-month pre-existing condition clause.Individual health insurance plan rates are set

on a singular basis and assume everyone is newto the health insurance medical underwritingprocess. Individual coverage plans do not offercontinuous coverage or deductible credit.

There are four things Arkansas Blue Crossmay do when someone has requested individualcoverage for himself/herself and/or family.1) Approve as applied — Applicant will receive

the coverage requested at the standard rate.2) Approve with exclusions — Arkansas Blue

Cross may exclude a condition or body partfrom coverage.

3) Approve with a surcharge — An applicantmay be charged an additional percentage ofthe base rate if the applicant is a smoker,regularly uses a specific medication, etc.

4) Reject the application.Approximately 75 percent of all applicants

are approved for individual health insurance,with 60 percent of applicants being approved asapplied (15 percent are approved with exclusionsor surcharges). Standard rates for individualhealth insurance plans are based on theapplicant’s ability to pass full medical underwrit-ing. When a person applies for individual healthinsurance and wants to include family members,each family member also must pass medicalunderwriting. If you misrepresent or omitmedical history information and do not discloseconditions or medications you are taking, yourindividual coverage may be rescinded.

According to DeBerry, it’s not true thathealth insurance companies only want healthypeople in their individual health insurance plans.Medical underwriting is based on a risk perspec-tive in relation to the applicant’s medical history.“Individual business is similar to property andcasualty insurance. I can’t tell you that your17-year-old son is going to be in a wreck in hisnew car, but I can tell you that it is more likelythan you being in a wreck,” said DeBerry. “Welook at on-going risk factors for conditions youmay have had or will have. You may have acondition that will manifest itself down the road.We make our decisions based on medical records

~~~~~~ Know the facts before you

What’s the difference betweenWhat’s the difference betweenWhat’s the difference between

17and by nationally published underwriting guidelines. Ittakes a lot of the subjectivity and guesswork out of it.”

Many people shopping for individual health insur-ance may already have group coverage but find that theycan receive a more affordable rate for their children orspouse with individual coverage. Additionally, peoplewith individual insurance only pay for the benefits theyneed. For example, a single 25-year-old male may sharethe cost of maternity coverage in a group plan butcould eliminate that cost with individual health insur-ance. With individual plans, the insured may pay lessin premium costs but may be required to pay ahigher deductible or more out-of-pocket expensesand coinsurance.

Group health insuranceGroup health insurance plans work differently than

individual health insurance plans. If you are employedwith a company that offers group health insurance,generally all you have to do is enroll and pay your shareof the premium, subject to the rules of the plan fortimely enrollment.

While large-group (50-plus employees) insurancegenerally is based on the group’s historical claims andmedical history, for small group coverage (2 to 50employees), you are required to complete medicalapplications for both yourself and family members thatyou plan to include in your group coverage. However,no matter what conditions you have or may have had,you can not be excluded from the group plan. Underwrit-ing may use the information to rate the group as awhole, but it will not exclude you from receivingmedical coverage.

Again, just as with individual health coverage, if youomit or misrepresent medical history information or donot disclose conditions or medications you are taking,your group coverage may be rescinded or terminated,and you will not be able to obtain health insurance fromArkansas Blue Cross in the future.

“If you are a diabetic and fail to disclose it on yourmedical enrollment form for group health insurance, youcan lose your coverage. We can’t exclude you from thehealth insurance plan for having diabetes if it is dis-closed; we just need everyone to be truthful in complet-ing their applications for rating purposes. It’s not enjoy-able for us to have to call someone and tell them theirinsurance is being canceled because the information on

their medical enrollment form was inaccurate. It’s a verydifficult thing to have to do … something we wouldprefer that everyone could avoid,” said David Green-wood, director of Enterprise Underwriting.

“People with health problems are aided by thesmall group insurance laws and regulations. Whiledisclosure may impact the group rates, it helps ensurehealth insurance coverage will be there when needed,”said Greenwood.

Even with group coverage, there are underwritingrules (set by the insurer) that impact the offering ofcoverage. Arkansas Blue Cross requires that all employerswho offer group plans to their employees have a certainpercentage of their eligible employees enrolled in theplan and that employers contribute a certain minimumpercentage to the premium cost of group healthinsurance.

Some people may recall theHealth Insurance Portability andAccountability Act (HIPAA) andbelieve that it provides for portabilityof coverage when they change jobs —whether they are with a group or areseeking individual health insurance.That is a misconception. It does allowan individual to continue groupinsurance coverage when there is ajob change, but it does not apply toindividual health insurance. It alsoallows for “creditable coverage” whichcredits past coverage when applyingpre-existing rules. Again, this applieswhen enrolling for group coveragewith a new company but not forindividual policies.

Whether you are enrolled in a group or individualhealth insurance plan at Arkansas Blue Cross, it is alwaysa good idea to look closely at all your options beforemaking a career or health insurance change. If you arethinking about leaving the protection of your grouphealth insurance plan for an individual plan — be sure toweigh all your options carefully. Health insurance shouldbe an important part of any career decision. If you havequestions about individual health insurance products,please call 1-800-392-2583 or visit our Web site atwww.arkansasbluecross.com.

decide to make a switch ~~~~~~

group and individual health plans?group and individual health plans?group and individual health plans?

18Members with our various health insurance

products occasionally receive a benefit explanation fromus that indicates a particular service has not been paidfor because the service was considered investigational.“Investigational,” as defined in the Arkansas Blue Crossand Blue Shield health planbenefit certificate, means that theservice (procedure, treatment,supply, device, equipment,facility or drug) does not meetone or more of the followingcriteria: 1) does not have finalapproval from the appropriategovernment regulatory body; 2)is being provided under a studythat requires approval by aninstitutional review board or similar body; 3) is beingevaluated in a controlled clinical trial or is otherwiseunder study to determine its safety or effectiveness; 4) issubject to question because the majority of publishedexpert opinion holds that further studies are needed todetermine its safety or effectiveness, or the majority ofpublished expert opinion shows lack of consensus eitherway; or 5) the majority of published expert opinion holdsthat it is unsafe or ineffective in the specific situation forwhich the service has been performed.

Pressure to pay for treatment based on inadequatestudies, early results of trials, and claims of effectivenessfrom promoters of the service, has become intense asmore new medical services have been developed. As aninsurer, we have a dual obligation to pay all valid claimsand to deny those claims that are not covered under amember’s health plan. Paying invalid claims could raisepremium costs for all our policyholders. In fulfilling thisobligation, we have developed a process for determiningwhether a service is “investigational” that we believeserves our entire membership most appropriately.

Our initial step is an analysis of the publishedmedical literature on the subject. This research is con-ducted by me or under my direction as medical directorand is reviewed by me or by our assistant medicaldirector. To help with this analysis, we review whatseveral other independent technology assessment groupshave said about the service. We also look for any posi-tion papers on the subject that have been published by

How coveragedecisions are made

certain national physician organizations. All usablestudies published in peer-reviewed medical literature arereviewed (unfortunately, many studies of the medicalliterature have shown that most research reports do notcontain usable data, and for emerging technologies, no

studies may exist). Advice then is re-quested from practitioners who would bemost knowledgeable about the service.After completion of this review, thecollected information is sent for review tomedical management committees in thevarious Arkansas Blue Cross regions.These committees are made up of practic-ing physicians of multiple specialties.Once a service is deemed investigational

by this process, claims for that service will be denied.If a member or his/her physician questions the initial

claims decision, it is reviewed by a registered nurse todetermine if the denial was adjudicated correctly andto determine if, for the particular member, the servicewas investigational in view of the member’s conditionand treatment regimen. If the nurse determines upon“re-review” that the service is not investigational asdefined in the health plan and should be allowed, theinitial denial of the service is reversed.

If the nurse determines that the denial was correct,the claim is then reviewed by a physician who is em-ployed by Arkansas Blue Cross. If this physician alsoagrees that the service is investigational, the specificclaim is referred for review to an outside physician in aspecialty that commonly provides the service. Afterreceiving the outside physician’s opinion, we thencommunicate the “re-review” decision to the member.

At this point, if the “re-review” decision is to denybenefits as “investigational,” the member has the right toformally appeal to the Arkansas Blue Cross appealscoordinator, who will evaluate all of the availableinformation and render a final claims decision.

A great deal has been written that health insurers, inorder to reduce claims payment, rely upon non-medicalpersonnel to make coverage decisions on whetherservices are investigational or not. Arkansas Blue Crosshas gone to great lengths to make certain that thesedecisions are made by medical personnel.

By James Adamson, M.D., medical directorfor Arkansas Blue Cross and Blue Shield

19The Pharmacist is inDo you have any questions?

The Pharmacist is inDo you have any questions?

More discountsfor members!

R a c e

&

Watch

Race For The Cure. If you are interested in raisingmoney and awareness for the fight against breast cancer,join 30,000 people who share your aspiration andparticipate in the Susan G. Komen Breast Cancer

Foundation’s 2001 ArkansasRace For The Cure on Saturday,Sept. 29, in downtown LittleRock. For more information,please call 501-202-4009.

Race Recap TelevisionSpecial. Then, tune into the 2001Race For The Cure Recap Show,presented by Arkansas Blue Crossand Blue Shield, at 6 p.m. onSept. 29, on FOX 16-TV and again

at 11 a.m. on Sunday, Sept. 30, on UPN 38-TV. You’ll getto relive the moments of the day during the 30-minutetelevision special which will highlight Race Day activi-ties. You may even see yourself “proud in the crowd.”

Run the race, then relax and watch the show.

Arkansas Blue Cross and Blue Shield is hard atwork canvassing the state looking for “wellness” dis-counts with health clubs, fitness centersand more — just for our members.

Fitness FX in Little Rock and theJacksonville Community Center are thenewest fitness centers in Arkansas tooffer discounts to our members.

If you are curious about whether your favorite fitnessspot offers a discount, visit the Arkansas Blue Cross Website at www.arkansasbluecross.com for a complete list ofparticipating fitness vendors. If you don’t see your work-out site on the list but would like Arkansas Blue Cross tocontact them about offering a discount to our members,just send the name and location of your fitness center toBNY-Ed@arkbluecross.com and we’ll take it from there.

A pharmacist is a valuable asset within the health care delivery system. It’s good to know that

patients have questions about the medications that havebeen prescribed for them. The thousands of medicationsavailable create an aura of mystery and curiosity topatients untrained in this fast-changing world of pharma-ceutical therapies. With this comes some anxiety anduncertainty for the patient. Having a healthy respectfor any medication you consume, whether prescribedby your physician or purchased over the counter, isimportant.

So, “The Pharmacist is in.” On a regular basis inBlue & You, the Arkansas Blue Cross pharmacy directorwill answer questions in this column submitted bycustomers and employers. Following is one of the mostfrequently asked questions and the answer.

Q: Why am I sometimes asked to change to a preferreddrug rather than the one I am taking?A: Some prescription medications are becoming exorbi-tantly expensive and are driving up pharmacy costs intoprice ranges where they are becoming unaffordable. Thesedrug costs are among the factors driving the steeply risinginsurance premiums across our nation. Most people whomust pay cash for their medications now are being faced

with serious decisions regarding the high cost of pre-scribed drugs. Those paying for health coverage are facedwith the same dilemma through their rising premiumexpense. Some employers have even discontinued pre-scription coverage in their health benefit plan and somepeople are going without needed medications.

The objective of recommending a preferred drug is toprovide quality pharmacy coverage at an affordable price.When the price of something becomes unaffordable, wejust do without. This may be acceptable in regard to whatwe “want,” but it is not acceptable when it comes to whatwe need to control diabetes, blood pressure or some otherchronic medical condition requiring medication. If youwere making the decision, you would want an effectivedrug that is safe and reasonably priced. These samestandards guide our decisions. It is important that wework together on this issue.

Arkansas Blue Cross is dedicated to working closelywith our members to help them understand more aboutwhat is transpiring in the area of pharmacy and whyparticular things are happening with medications. If youhave a question about medications or drug coveragepolicies, please submit your question via e-mail toBNYou-Ed@arkbluecross.com. Questions submitted bycustomers will be answered in this column in futureissues of Blue & You as space permits.

20At Arkansas Blue Cross and Blue Shield, we under-

stand how important it is to keep your private informa-tion just that — private. Because of the nature of ourbusiness, Arkansas Blue Cross must collect some per-sonal information from our members, but we also arecommitted to maintaining, securing and protectingthat information.

Customer InformationArkansas Blue Cross only compiles information

necessary for us to provide the services that you, ourmember, request from us and to administer your busi-ness. Arkansas Blue Cross collects non-public personalfinancial information (defined as any information thatcan be tied back to a specific person and is gathered byany source that is not publicly available) about ourmembers from:• Applications for insurance coverage. The application

includes information such as name, address, personalidentifiers such as Social Security number and medicalinformation that you authorize us to collect.

• Payment history and related financial transactionsfrom the purchase and use of our products.

• Information related to your status as a current orformer member.

Sharing of InformationArkansas Blue Cross does not disclose, and does not

wish to reserve the right to disclose, non-public personalinformation about you to our affiliates or other partiesexcept as permitted or required by law. Examples ofinstances in which Arkansas Blue Cross will provideinformation to affiliates or other third parties are:• To service or process products that you have re-

quested.• To provide information as permitted and required by

law to accrediting agencies.• To provide information to comply with federal, state or

local laws in an administrative or judicial process.

How We Protect Your InformationArkansas Blue Cross uses various security mecha-

nisms to protect your personal data including electronicand physical measures as well as company policies thatlimit employee access to non-public personal financial

Arkansas Blue Cross and Blue Shield

Financial Information Privacy Noticeinformation. Improper access and use ofconfidential information by an employee can result indisciplinary action up to and including termination ofemployment.

Disclosure of Privacy NoticeArkansas Blue Cross recognizes and respects

the privacy concerns of potential, current and formercustomers. Arkansas Blue Cross is committed to safe-guarding this information. As required by a new stateregulation, we must notify our members about howwe handle non-public financial information of ourmembers. Nothing has changed in the way we conductour business. If you would like to review the FinancialInformation Privacy Notices for all Arkansas Blue Crossmembers, you can visit our Web site atwww.arkansasbluecross.com or call the appropriateArkansas Blue Cross company to receive the PrivacyNotice. Our Customer Service areas are open 8 a.m.–4:30 p.m., Monday through Friday.

To receive a copy of the Privacy Notice, membersshould call:

Medi-Pak HMO — 1-800-354-9904Arkansas Blue Cross — 1-800-238-8379USAble Administrators — 1-888-USABLE1

(Call between 8:15 a.m. – 4:30 p.m., CentralTime, Monday through Friday. USAble Adminis-trators is a division of The First Pyramid LifeInsurance Company of America that providesthird-party administrator services.)

First Pyramid Life — 1-800-519-2583Health Advantage — 1-800-843-1329.

Some of the cancer information in this issue of Blue &You was provided by the American Cancer Society. Formore information on cancer — and cancer prevention —you may contact the nearestchapter of the AmericanCancer Society or call1-800-ACS-2345 or visitthem on-line atwww.cancer.org.

Growing by sheeps and boundsIn less than two years, the BlueAnn Health and Class

Clubs have grown by sheeps and bounds. To date, almost12,000 kids are learning important health lessons fromArkansas Blue Cross and Blue Shield’s health ambassa-dor, BlueAnn Ewe, a big, blue sheep!

The BlueAnn Clubs are part of the Arkansas BlueCross Blue & Youth Health Program, a health educationeffort designed to improve the well-being of Arkansascitizens, beginning with the young people of the state.

The BlueAnn Health Club is a free health club witha two-year membership, designed to provide individualchildren ages 5 to 10 with opportunities to learn abouthealthy lifestyles and participate in activities, with thegoal of encouraging overall healthy behaviors andinvolving parents in the process. The Health Clubincludes incentives and rewards for participating inactivities and includes an ID card and membershipcertificate. Following the initial membership packet,Health Club members receive quarterly packets, whichinclude a newsletter,activity sheet anda specialgift.

Packetsalso containinformation and activitieson health topics, includingnutrition, exercise, safety,hygiene, dental health, emotions and drug/tobaccoprevention.

To date, 1,661 individuals have joined theHealth Club.

The BlueAnn Class Club is the classroom equivalentof the Health Club. This free club is designed for kinder-garten and first-grade classrooms. Teachers enroll theirclasses and utilize the Class Club materials at their

discretion. Membership is for one school year and alsoprovides incentives and rewards for practicing healthybehaviors. Class Clubs get three packets of informationand activities during the school year focused on physicaland emotional health.

In the 2000-01 school year, 448 classeswere enrolled in the Class

Club with atotal of 10,062elementaryschool-agedstudents reachedwith fun healthmessages.

If you are aparent or teacherand would like toenroll your kids orstudents in one of theclubs, please call toll-free 1-800-515-BLUE(2583). Or you can visit

B lueAnn ’s Wild and Woolly Web site atwww.BlueAnnEwe-ark.com.

It’s fun. It’s free. And you can help your kids be theirhealthy best with the assistance of a woolly blue friend.

Note: You can learn who the Class Club “Build aHealthy Sundae” party winners for the 2000-01 schoolyear were in the Blue & Your Community section of thisissue of Blue & You on Page 23.

Ice cream chef BlueAnn visits Carver Magnet ElementarySchool Class Club in Little Rock for a “Build a HealthySundae” party.

Health Club membersperiodically receive inthe mail health-and-wellness newslettersand a colorful BlueAnnposter for their wall.

22 ASE/PSE

members —

take note!

IMPORTANT NOTICE FOR PUBLIC

SCHOOL AND STATE EMPLOYEES

The state of Arkansas EmployeeBenefits Division has announcedthe addition of a new BehavioralHealth Program for Public SchoolEmployees and Arkansas StateEmployees, effective Oct. 1, 2001,and Jan. 1, 2002, respectively.

CORPHEALTH, Inc., a nationalbehavioral health company, hasbeen selected by the ArkansasEmployee Benefits Division toadminister mental health andsubstance abuse benefits and anemployee assistance program. Inorder to qualify for reimbursement,all behavioral health care servicesmust be pre-authorized and man-aged by CORPHEALTH. In addition,a CORPHEALTH network providermust deliver all covered non-emergency care. Call theCORPHEALTH Arkansas Help Linetoll-free at 1-866-378-1645 for moreinformation. The toll-free Help Lineis available to members and provid-ers 24 hours a day, 365 days a year.

This program and CORP-HEALTH are not affiliated withArkansas Blue Cross and BlueShield or Health Advantage. Pleasenote that on the effective date ofthe program, mental health andsubstance abuse claims should notbe submitted to Arkansas BlueCross or Health Advantage, as thesebenefits are excluded and there isno secondary coverage. For publicschool and state employees, ourdirectories of participating providerswill no longer list any mentalhealth providers.

Primary care physicians are nolonger responsible for referrals orpre-certifying mental health andsubstance abuse care.

TRANSITION SERVICES ON OR AFTER

THE EFFECTIVE DATE

If members are actively in-volved in mental health or sub-stance abuse treatment or employeeassistance, the member(s) will be

responsible for contactingCORPHEALTH to coordinatetransition of care. All mental healthand substance abuse care andemployee assistance provided on orafter the effective date must be pre-certified by CORPHEALTH.

Questions regarding CORP-HEALTH should be referred to thetoll-free number, 1-866-378-1645.

PRESCRIPTION DRUG COVERAGE FOR

PUBLIC SCHOOL AND ARKANSAS STATE

EMPLOYEES

The decision to useCORPHEALTH is similar to thepublic school and state employeesusing Advanced PCS for prescrip-tion drug benefits. For both of theseprograms, Arkansas Blue Cross andHealth Advantage are not affiliatedwith and cannot provide informa-tion on coverage or benefits.

Questions regarding AdvancedPCS should be referred to the toll-free number 1-877-456-9586.

The Women’s Health and Cancer Rights Act of1998 introduced changes in insurance coverage formastectomy.

In accordance with the law, all group and individualhealth plans that provide medical and surgical benefitsfor mastectomy now cover reconstructive breast surgery,if elected by the covered individual following mastec-tomy, including:• Reconstructive surgery on the breast on which the

mastectomy was performed.• Reconstructive surgery on the unaffected breast

needed to “produce a symmetrical appearance.”• Prostheses and treatment of complications of any stage

of a mastectomy, including lymphedema.

The provisions of the Act apply to all group healthinsurance coverage effective on the first day of the planyear (which in most cases is the anniversary date of thegroup contract) after Oct. 21, 1998. The law went intoeffect on all individual insurance policies issued, re-newed or in effect on or after Oct. 21, 1998.

These provisions apply to all policies issued byArkansas Blue Cross and Blue Shield, Health Advantageand USAble Administrators and are subject to the appli-cable co-payments, coinsurance, benefit limitations,exclusions and benefit maximums.

If you have questions about your insurance coverage,contact your group benefits administrator or your localArkansas Blue Cross office.

Women’s Health and Cancer Rights Act YULZNMa

23Arkansas Blue Cross and Blue Shield strives to be a

good corporate citizen. Our employees raise money andspend many hours helping those causes near and dear tothe hearts of Arkansans.

Mid-week SundaesElementary school students in six schools in Arkan-

sas made creamy creations with the assistance ofBlueAnn Ewe, ambassador of health and wellness forArkansas Blue Cross at “Build a Healthy Sundae” partiesin their classroom. The students, who are members ofthe BlueAnn Class Club,completed a HealthyHabits Activity Calendarunder the direction oftheir teachers to becomeeligible for a “Build aHealthy Sundae Party”with BlueAnn in theirclassroom. (A randomdrawing was held amongthe eligible classrooms.)To complete the HealthyHabits Activity Calendar,students practiced at least one healthy habit each day —brushed their teeth, etc. — and recorded their habitswith a sticker on a calendar for 20 school days. As areward for their efforts, BlueAnn Ewe visited six class-rooms and served the students frozen vanilla yogurtwhich they topped off with healthy treats such as granolaand fresh bananas. The students played games withBlueAnn, and watched and learned the words toBlueAnn’s music health videos. Winners of the Spring2001 sundae parties were: (Northwest) First GradeTeacher: Sheila Curtis, School: Northside Elementary inSiloam Springs; (West Central) First Grade Teacher:Deborah Marshall, School: Sutton Elementary in FortSmith; (Southwest) First Grade Teacher: Tonya Dounphy,School: Union Elementary in Texarkana; (Central) SecondGrade Teacher: June Joseph, School: Carver Magnet inLittle Rock; (Southeast) K-5 After-school programTeacher: Frances Moncrief, School: Holy Rosary inStuttgart; and (Northeast) Kindergarten Teacher: MargieRoach, School: Westside Elementary in Jonesboro.

Blue at the ZooOf all the unique animals at the Little Rock Zoo,

BlueAnn Ewe was the only blue, woolly one seen walk-ing around during Zoo Days held June 9 and 10.BlueAnn was on hand to greet kids of all ages whovisited the animal attractions during the zoo’s annualevent designed to raise money for and awareness of itsprograms and wild residents. More than 8,500 peoplecame through the gates — more than twice as many asthe past two years combined — during the two-daycelebration which featured lots of fun and educationalactivities, special guests and live entertainment for theentire family.

River Market FiestaHoppin’ jalapeños! The River Market in Little Rock

was a hot, happenin’ place on July 7 as Arkansas BlueCross helped celebrate the site’s anniversary at its Fifth-year Fiesta. Feeling right at home in the midst of theFarmer’s Market, BlueAnn Ewe greeted kids and theirparents who stopped in to select fresh produce andparticipate in festivities. Kids enjoyed watching themaking (and taking home) of balloon animals, pettingreal animals, and trying to break colorful piñatas for thesurprises inside. More than 50 kids signed up for theBlueAnn Health Club at the event.

“Corporation of the Year”Arkansas Blue Cross recently was recognized as the

“Corporation of the Year” at the 15th Annual ArkansasMinority Business Opportunity Fair luncheon heldWednesday, June 13. The award was given for excellenceand dedication in utilizing minority businesses inArkansas, and acknowledges that the company’s “com-mitment and long-term support have established Arkan-sas Blue Cross as a leader and pacesetter in corporateAmerica.” Garold Lessig, Arkansas Blue Cross purchasingagent, accepted the award on behalf of Arkansas BlueCross. “Recognition of this nature is a result of ourcombined efforts within Purchasing and other depart-ments to establish quality relationships with smallbusinesses,” said Lessig. “Although this award recognizesthe initiative of doing business with Arkansas minoritybusinesses, considerable activity also takes place withminority businesses outside of the state,” he added.

BlueAnn Ewe shows students ofUnion Elementary in Texarkanahow a “chef in sheep’s clothing”serves up ice cream sundaes.

www.arkansasbluecross.com&

www.healthadvantage-hmo.com

Arkansas Blue Cross and Blue ShieldP.O. Box 2181Little Rock, AR 72203-2181

Members and policyholders of Arkansas Blue Crossand Blue Shield and Health Advantage often havequestions about their health care benefits and services.Arkansasbluecross.com and healthadvantage-hmo.comoffer several ways to find answers.

Contact UsIn the “Contact Us” section, accessible from the

bottom of the home page or the navigation bar to the leftof the internal pages, a link called “Helpful Information”provides a list of phone numbers.

On both sites, visitors will find local and toll-freenumbers for specific health plans and Customer Service.The page also contains a link to a regional offices mapand directory and a link to the Customer Service e-mail.

Providers of medical services will find a list ofnumbers especially for them under “Provider InformationLines.” They also will find a list of network developmentrepresentatives under the “Contact Our Regional Offices”heading.

Regional OfficesWeb site visitors can find the “Regional Offices” link

by going to the footer at the bottom of the home page orthe navigation bar on the left side of the internal pagesand clicking on “Contact Us,” “About Us” or “CustomerService.” On the “Regional Offices” page, a map outlinesour seven regions; and a directory lists each regionalexecutive’s name, a mailing address, a local and toll-freecustomer service number and a fax number.

Customer ServiceThe “Customer Service” section of both sites,

accessible from the bottom of the home page or thenavigation bar to the left of the internal pages, containsinformation on these topics:• Fraud and Abuse — how to report suspected

insurance fraud and abuse;• FAQ — questions commonly asked by customers;• Glossary of Terms;• Wellness Discounts — health clubs, fitness

equipment dealers, diet centers and other businessesthat offer discounts to health-plan members.

Value-Added Services“Health Plans and Services,” found on both sites,

links from the home-page footer or the bar to the left ofeach major internal page. In this section is a link called“Value-Added Services,” which are services provided tomembers and policyholders at no additional cost:• Special Delivery — helps educate expectant mothers;• BlueCard® — extends health care benefits while

members are temporarily out of the service area;• Health Education Programs — features programs for

specific diseases;• Utilization Management — helps control costs.

E-mail Customer Service and WebmasterOn the home page of both sites and at the bottom of

each major page, the link called “E-mail CustomerService” goes to a mailbox for customer servicerepresentatives. Site visitors should be aware, however,that this e-mail is not totally secure. It is better not tosend personal medical information this way. Visitors whoexperience problems with the site or have suggestionsshould use the “E-mail Webmaster” link.

* * * Don’t Forget To ... * * *… return the survey cards found in this issue of Blue &You for a chance to win one of three $50 Best Buy giftcards or one of three $50 Wal-Mart gift certificates.