In recent years, insurers have tried to cajole consumers into using less-expensive health-care providers by promising lower co-payments and other cost-sharing breaks for members who select those doctors and hospitals.

Lately, they're trying an even more direct approach: cash rewards.

Some Anthem Blue Cross and Blue Shield members in New Hampshire, Connecticut and Indiana can receive $50 to $200 if they get a diagnostic test or elective procedure at a less expensive facility than the one their doctor recommended. The offer covers nearly 40 services, from standard radiology tests such as mammograms and MRIs to such surgical procedures as hip and knee replacements, hernia repair, bariatric surgery and tonsillectomies.

"We identified a subset of highly utilized services with cost variances that we thought would have a big impact," says Denise McDonough, regional vice president of sales for Anthem BCBS of New Hampshire. "We want to provide information to members to drive health-care costs down."

It seems to be working. The city of Manchester, N.H., the first employer to pilot Anthem's Compass SmartShopper program in January 2010, has saved more than $250,000 in health-care costs in two years, even after factoring in the cash rewards paid to the 476 members who have participated.

The differences in costs can be eye-popping. According to Anthem data, in Manchester a hernia repair ranges in price from $4,026 on the low end to $7,498 on the high end. A colonoscopy could cost $1,450 to $2,973.

"It was a huge eye-opener for us," says Jane Gile, human resources director for the city government.

It, of course, can also save money for employees who haven’t met their plan's deductible.

Here's how the SmartShopper program works. At least 24 hours before a member has a scheduled service, he or she calls a toll-free number or logs on to a Web site to get a list of lower-cost local providers.

If a doctor has referred someone to a location that's not on the list of cheaper providers, the member can request that the doctor change the referral. If the physician is performing the procedure, the member can ask that the doctor do it at a cheaper location.

After the provider submits the claim and Anthem pays it, the insurer compares the records of online and telephone inquiries made by the member to the SmartShopper program. If the member chose to get care at a low-cost provider identified by the program, he gets a check in the mail within 60 days. (The amount is usually about $100, but it varies with the size of the amount saved.) An employee who has not yet met his annual deductible would also save directly on the cost of the treatment.

If the member wants to stick with his doctor's initial plan and forgo the cash bonus, no problem. The program is entirely voluntary.

Last year, Harvard Pilgrim Health Care launched SaveOn, a similar program that covers a limited number of services in New Hampshire and that recently expanded into Massachusetts.

Physician groups have some concerns. "It appears as though the decision is being made by the health plan, and tiering of providers is being made simply on an economic basis," says Scott Colby, executive vice president of the New Hampshire Medical Society. "We have concerns about giving economic incentives without giving weight and credence to quality measures."

It's a fair criticism, insurers concede. Listed providers are licensed and credentialed, but quality indicators such as complication rates aren't factored in. "It's a first-generation set of data," says Eric Schultz, president and chief executive of Harvard Pilgrim Health Care. "We all have a long way to go on performance data."

Likewise, the Compass SmartShopper FAQ page says, "It is up to you to talk to your doctor or research online at anthem.com to determine your quality requirements."

For simple diagnostic lab and radiology procedures, choosing providers based primarily on cost is probably fine, says Ha Tu, a senior researcher at the Center for Studying Health System Change, a Washington-based think tank. "But when you start talking about surgery, it's hard to argue that quality doesn't vary quite a bit, and people shouldn't be making these decisions purely on cost."

Physicians are also concerned that programs such as SaveOn and SmartShopper may hinder care coordination among providers at a time when such coordination is considered key to managing patients' health and controlling health-care costs.

When the SmartShopper program was introduced, some Manchester city employees were skeptical, says Gile. But many have come around.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

The "uninsurables"-- people with serious medical conditions who can't buy health coverage on the private market -- are supposed to have a safety net to rely on in the new preexisting condition insurance plans (PCIPs). These comprehensive plans, created by the federal health care law, take all comers who have been uninsured for at least six months. The premiums can be expensive, however, running several hundred dollars a month.

In many states, people with medical conditions such as HIV/AIDs, hemophilia, kidney disease and cancer can get a helping hand from government programs or nonprofits that pay the PCIP premiums on their behalf. But a handful of states have decided to prohibit third parties from picking up the tab.

Iowa is one of them, and in recent months the situation there has generated plenty of public controversy.

Some Iowa health officials would like to use federal funds from the AIDS Drug Assistance Program to pay the PCIP premiumsfor residents who have HIV/AIDS. That way, these people could receive coverage for doctor visits and other medical needs in addition to drugs.

"When [officials] announced the PCIPs, they conveyed that this would be one of the solutions for people with HIV," says Randy Mayer, the Iowa public health bureau chief in charge of HIV, sexually transmitted infections and hepatitis. He estimates that at least 100 people, and "probably considerably more," could benefit.

But the board that runs the Iowa PCIP sees the situation differently. "We've been given a certain amount of money to manage this program, and we don't know what will happen if we run out," says Cecil Bykerk, the executive director of the board that manages the Iowa program. Bykerk, a former chief actuary in the insurance industry who has extensive experience working with state high-risk pools, also oversees the programs set up by Montana and Alaska.

Overall, the PCIP program received $5 billion to fund plans nationwide until 2014, when insurers will be required to cover everyone regardless of their health. Although only 49,000have signed up, far fewer than originally projected, those who are enrolled have higher medical costs than expected.

Iowa was allocated$35 millionuntil 2014 and used about $4 million by the end of last year, less than they had expected. By April 1, the Iowa plan will have 282 members, "slightly under" projections for this time, says Bykerk.

A number of states, including Alaska and Montana, have overrun their spending projections and asked for and received additional federal funding. But Bykerk doesn't want to risk that in Iowa.

"Being unsure of all this, the board is hesitant to move forward and ask to amend the contract to permit third-party payment," he says.

There are legitimate reasons why states have concerns about third-party payments: If an employer or insurer is permitted to pay someone's PCIP premium, for example, it may be tempted to dump people into those plans rather than insure them and absorb the cost of their care. Likewise, hospitals and other health-care providers might benefit financially by paying the premiums for people with serious medical needs, thereby encouraging them to receive care at those institutions, including possibly unnecessary care.

The federal government runs the PCIPs in 23 states and in the District of Columbia. Those jurisdictions permit third-party payment, at least for now. In its guidance on the plans, the Department of Health and Human Services says it will monitorsuch payments closely, and "to the extent that HHS finds that these payments present conflicts of interest or contribute to greater than projected spending, HHS anticipates that it will issue further guidance that restricts or even prohibits third-party payments for premiums."

The remaining 27 states run their own PCIPs with federal dollars. A handful of them don't allow third-party payment, according to HHS. They include: Arkansas, Connecticut, Iowa, Maine, Montana, Oklahoma, Pennsylvania and Rhode Island. Frequently, states followed the third-party payment rules they had in place for their own high-risk pools, which also cover people with pre-existing conditions but don't target the uninsured to the same degree.

In New Mexico, about 11 percent of the 950 people enrolled in the PCIP get their premiums covered by such third parties as the American Kidney Fund, the University of New Mexico and the New Mexico Department of Health, says Deborah Armstrong, executive director for the New Mexico Medical Insurance Pool, which is both the PCIP and the state high-risk pool.

The state's original enrollment projection was just 650 to 700, so as more people have signed up, "they're just adjusting our contract for what we need," she says.

A year ago, Eli Valdez, 36, had full-blown AIDs. Uninsured and earning just $1,000 a month as a cashier at a pizza parlor, he had racked up more than $35,000 in medical bills. The $1,600 he needed monthly for prescriptions was covered by the state, but because he couldn't afford physician visits or blood work, the Albuquerque resident wasn't monitoring them as he should have.

Now he has comprehensive insurance through the New Mexico PCIP, for which the nonprofit community group New Mexico AIDS Services pays the $336 monthly premium.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

The federal healthcare reform law has eliminated lifetime limits on health insurance for more than 105 million Americans, according to a report released March 5 by the U.S. Department of Health and Human Services.

Previously, individuals with health insurance who had serious illnesses like cancer were at risk of hitting the lifetime limit on the dollar amount their insurance companies would cover for their health benefits.

The most common lifetime limit policies set by insurance companies were $1 million and $2 million.

"For years, Americans with lifetime caps imposed on their health insurance benefits have had to live with the fear that if an illness or accident happened, they could max out their health coverage when they needed it the most,” HHS Secretary Kathleen Sebelius in a press release.

While some plans provided coverage without dollar limits on lifetime benefits, 105 million Americans were previously in health plans that had lifetime limits. Beginning Sept. 23, 2010, the Patient Protection and Affordable Care Act prohibited health plans from imposing a lifetime dollar limit on most benefits received by Americans for any health plan renewing on that day or afterward.

In 2009, 59 percent of all workers covered by their employer’s health plan had some kind of lifetime limit placed on their benefits. In addition, 89 percent of people who purchased individual insurance coverage had a lifetime limit on their health coverage.

HHS estimates that 70 million people in large employer plans, 25 million people in small employer plans, and 10 million people with individually purchased health insurance had lifetime limits on their health benefits prior to the passage of the Affordable Care Act in March 2010.

When Ronda Austin's employer stopped offering health coverage last spring, she bought an individual policy from Blue Cross and Blue Shield of Florida. A month later she was given a diagnosis of multiple myeloma and began chemotherapy at her oncologist's office near her home in Tampa.

But after several sessions, the physician's office said that her plan covered chemotherapy only if it was provided in a hospital and told her she owed the practice $15,000. Austin called her plan's member-services number but didn't get anywhere.

So she stopped in at a new kind of insurance facility— her local BCBS of Florida retail store. There, a customer service rep sat down with her and called up her plan information online. She referred Austin to nearby Moffitt Cancer Center for subsequent chemotherapy treatments and explained how to address the problem with the oncologist's billing department, which had misread her policy. The problem was quickly resolved.

"It's a great feeling to know the insurance company is standing behind you," says Austin.

Health insurers increasingly want to make shopping for a new health plan as easy and convenient as dropping into a local retailer to buy a TV. In recent years, a number of them have opened stores where consumers can stop by to talk with a customer service representative about buying a plan or resolve questions about their current coverage. Some stores also sponsor health fairs or community seminars on nutrition and exercise. A few have primary-care doctors on-site.

"The stores are big, bold and easy to see," says Marc Pierce, president of Stonegate Advisors, a research and strategy company in Chicago that has helped several insurers evaluate retailing. "For insurers, the impetus is to provide a tangible touchpoint so they can provide more value for their customers." The trend should continue, he says, unless the U.S. Supreme Court strikes down the 2010 health-care law.

The number of individual health insurance customers is expected to grow significantly in coming years. Employer-sponsored health coverage is eroding, and in 2014 the law will require nearly everyone to have insurance, adding millions to the ranks of the insured.

The stores are "a reaction to the shift from wholesale to retail in insurance sales," says Paul Ginsburg, president of the Center for Studying Health System Change. "In wholesale sales, employers were the buyers. Now insurers are recognizing thatretail will be more important."

Bricks and mortar

Insurers Highmark in Pennsylvania and BCBS of Florida have the largest retail presence to date, with several stores throughout those states. In New York, UnitedHealthcare recently opened a 16,000-square-foot facility in the Flushing section of Queens;it operates a number of smaller storefronts as well.

As insurers see it, bricks-and-mortar stores are one more way, along with online and telephone support, to reach out to consumers. "This is a third service option for people that like high-touch service," says Craig Thomas, senior vice president for consumer and government markets at BCBS of Florida.

Insurers also hope that their visible presence in communities may generate some positive buzz. "We don't really drive a whole ton of word-of-mouth on the positive side," says Matt Fidler, vice president of consumerism and retail marketing at Highmark,a BCBS plan.

BCBS of Florida and UnitedHealthcare both emphasize providing comprehensive services. At the Queens store, for example, visitors, many of them Asian American Medicare and Medicaid beneficiaries, can get their claims questions answered in their native languagesand get help signing up for social services programs such as food stamps and a pharmaceutical assistance program for seniors.

"We want to afford people a 360[-degree] experience, and give people access to all the information they need to take careof their health care," says Yasmine Winkler, UnitedHealthcare's chief product and marketing officer. Offering a smorgasbord of services also keeps people coming back, creating consumer "stickiness," she says.

Strip mall service

In Pennsylvania, Highmark stores focus on sales. Ninety percent of the traffic at its eight stores is sales-related, says Fidler. 

After being laid off from her job, Heather Manning bought insurance at the Highmark store at a strip mall in Easton shortly before her second child was due.

Although she wasn't able to get coverage for herself until after she had the baby— her pregnancy was a preexisting condition, which individual insurance policies typically don't cover— she bought coverage for her 6-year-old son. Once the baby was born in January, she bought a separate policy for the two of them. She pays $400 a month for all three of them.

The experience was very positive, she says. Before signing on with Highmark, she had gotten online quotes from several other insurers, which led to a barrage of sales calls from agents.

Highmark customer service reps, however, don't get sales commissions. "It sets the tone to have it be educational," says Fidler. "It differentiates us [from brokers] from the get-go."

Although there are many upsides to the new insurance stores, Pierce cautions that they could backfire. Consumers already think that health plans make too much money, he says. "Here's the potential for consumers to say, 'Why are you building this big store? Why don't you just reduce my premiums by 20 percent?'"

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

In the heated debate over to what extent religiously affiliated employers should be required to provide free contraception for workers, no one has talked much about what methods are available to women who want to prevent pregnancy and how their choices might change if cost were removed from the equation. But it's an important subject.

With prices ranging from about $1 for a condom to more than $800 for an intrauterine device (IUD), some of these women, maybe a lot of them, might switch methods if they could afford to.

That's exactly what many women's health advocates hope. Long-acting methods such as the IUD and the hormonal implant are nearly 100 percent effective, require no effort after insertion and protect against pregnancy for up to 10 years. (In contrast, birth control pills are about 92 percent effective, and many other common methods are even less reliable in everyday use.)

Some women worry that having a device inserted in the uterus or under the skin is riskier than methods such as a pill, a patch or a vaginal ring that they can discontinue at will.

But experts such as Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a nonprofit research center on reproductive policy, point out that IUDs and implants "eliminate the possibility of inconsistent use."

They're also among the most cost-effective methods available in the United States, according to research by James Trussell, a professor of economics and public affairs at Princeton University. Among other things, Trussell factored in the cost of particular methods, their effectiveness at preventing pregnancy, and the costs of unintended pregnancy or other events during a five-year period. IUDs and vasectomies were found to be the most cost-effective. Implants were somewhat less cost-effective but still a better bet than oral contraceptives, the patch, the vaginal ring or injectable contraceptives, among others.

These longer-acting methods, however, carry a hefty upfront price tag of between $500 and $1,000 for the device itself and its insertion. Meanwhile, insurance coverage is uncertain. Although the vast majority of employer health plans cover contraception, they don't necessarily cover all methods and they generally don't cover them for free. A 2004 study found that 40 percent of companies covered IUDs.

"For most plans, the devices aren't considered part of the drug formulary, so you might have coinsurance of some amount like 20 percent," Sonfield says.

Health Care Reform

Under the new health care law, starting this August, new employer health plans or those that change their benefits substantially will be required to cover all FDA-approved contraception methods and related counseling without co-pays. Catholic bishops and others strenuously objected to imposing this requirement on employers who objected to contraception on religious grounds. The Obama administration last week offered a compromise that would allow women who work for religious organizations to obtain contraception directly from an insurer -- still without co-pays. But the debate continues.

Although eliminating cost concerns may help encourage the use of longer-acting methods, that's only half the battle. Educating women and providers is also critical, say experts. Many people still associate IUDs with the Dalkon Shield, a device marketed in the early 1970s that led to severe infections, infertility and death, resulting in hundreds of millions of dollars in legal claims.

"The Dalkon Shield put a chill on IUDs for the next four decades," says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.

Only 5.5 percent of women practicing birth control used an IUD in 2006-2008. An even smaller percentage used hormonal implants, which received FDA approval in 2006. In contrast, 28 percent of women used birth control pills.

The longer-acting methods currently approved by the FDA are considered safe and effective. They include two IUDs, Mirena and ParaGard. These small T-shaped devices are inserted into the uterus and release hormones or small amounts of copper to prevent fertilization for five or 10 years, respectively. Implanon is a matchstick-sized hormonal implant that, once inserted under the skin of the upper arm, prevents pregnancy for three years.

Education Effort

The Contraceptive Choice Project is testing the idea that by educating women about longer acting methods and removing cost barriers, more will decide to use them and fewer will become accidentally pregnant.

In 2007, researchers at Washington University in St. Louis began to enroll 10,000 women in that region, offering them free contraceptives of any type for three years and focusing on educating them about longer-acting methods.

Seventy-five percent chose IUDs or implants, a much higher proportion than the 5.5 percent in the general population. After a year, 86 percent of those using IUDs or implants decided to continue with the longer acting method; only 55 percent of the women who were taking birth control pills continued with that method, according to preliminary figures from the researchers.

"Women should be able to control their reproductive lives," says Jeffrey Peipert, principal investigator for the project who is vice chair for clinical research in the department of ob/gyn at the Washington University School of Medicine. "But with our current system, so many people are uninsured or unable to pay for their birth control."

Happy With Her Choice

Lydia and Drew Huston have three children and don't want any more. When Lydia, now 44, heard about the research project at the university near their home in Florissant, Mo., she signed up. Three years of free contraceptives sounded like a good deal.

Until she enrolled in the study, Huston had been getting hormonal Depo-Provera shots every three months to prevent pregnancy. Her co-pay was $20 each time. Although it was better than having to take a pill every day, getting to the doctor even once every three months was tough given her family commitments and her job working in development at a nonprofit organization.

Before meeting with the university researchers, Huston never understood the longer-acting options that were available. "They gave me this array of information," she says. "It was so empowering." After discussing the methods, Huston decided on a hormonal implant, which would last for three years. It was an easy transition from the injections she'd been receiving earlier.

Huston is happy with her choice. "Knowing what I know now, if I had to pay for a longer-acting method I would."

Millions of Americans took advantage of new free preventive health services in 2011, according to new figures released Feb. 15 from the U.S. Department of Health and Human Services.

Approximately 54 million Americans received at least one new free preventive service in 2011 through their private health insurance plans. A myriad of preventive services – including diabetes screening, immunization vaccines and diet counseling – are now covered by insurance companies at no extra cost to consumers under the Patient Protection and Affordable Care Act.

Beginning Aug. 1 of this year, new preventive services specifically for women will also be provided for no extra costs to patients including cervical cancer screening, anemia screening, contraception and HPV testing.

HHS also estimates that 32.5 million people with Medicare received at least one free preventive benefit in 2011, including the new annual wellness visit, since the health reform law was enacted in March 2010.

Together, this means an estimated 86 million Americans have been able to receive preventive health services for no charge, according to two new HHS reports.

The Affordable Care Act requires many insurance plans to provide coverage without cost sharing to enrollees for a variety of preventive health services, such as colonoscopy screening for colon cancer, Pap smears and mammograms for women, wellness visits for children and flu shots for all children and adults. The law also makes many preventive services free for most people on Medicare.

The HHS report on private health insurance coverage also examined the expansion of free preventive services in minority populations. The results showed that an estimated 6.1 million Latinos, 5.5 million African Americans, 2.7 million Asian Americans and 300,000 Native Americans with private insurance received expanded preventive benefits coverage in 2011 as a result of the new healthcare law.

The report discussing Medicare preventive services found that more than 25.7 million Americans in traditional Medicare received free preventive services in 2011. Among Medicare Advantage plans, the report found that 9.3 million Americans – 97 percent of those in individual Medicare Advantage plans – were enrolled in a plan that offered free preventive services. Assuming that people in Medicare Advantage plans utilized preventive services at the same rate as those with traditional Medicare, an estimated 32.5 million people benefited from Medicare’s coverage of prevention with no cost sharing.

As the gap in wealth among Americans continues to widen, so does the divide in health insurance and access to health services.

A new study released Feb. 7 finds that adults in low- and moderate-income families are more likely to be uninsured, to lack a regular source of healthcare, and to struggle to get necessary health services compared to individuals in higher-income families.

"We expect to see a widening gap in healthcare over the next several years,” Sarah Collins, vice president for Affordable Health Insurance at the Commonwealth Fund, said during a Feb. 6 media briefing.

Nearly three of five – or 57 percent – of those in families earning less than 133 percent of the federal poverty level were uninsured for a time in 2011 while two out of five were uninsured for one or more years, according to the first Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults. More than one-third – or 36 percent – of adults in moderate-income families – those earning between $29,726 and $55,875 for a family of four – were uninsured during the year, and 18 percent had been uninsured for two years or more.

Low- and moderate-income adults who were uninsured during the year were much less likely to have a regular source of healthcare than people in the same income range who were insured all year. In addition, uninsured lower-income adults were more likely than insured adults in the same income group to cite factors other than medical emergencies as reasons for going to the emergency room. These included needing a prescription drug, not having a regular doctor, or saying that other places cost too much.

In contrast, just 12 percent of adults in families with incomes at or above $89,400 for a family of four were uninsured during the year, and only 3 percent were uninsured for two years or more.

"The urgency for looking at this group is underscored by the widening income divide in the U.S. as a whole,” Collins said. "Because lower income adults are more likely to lack health insurance coverage they are also disproportionately likely to lack access to care.”

Lack of health insurance coverage, as well as income, had a significant impact on how often individuals accessed care, such as recommended preventive services. Just 10 percent of low-income uninsured adults age 50 and over had received screening for colon cancer, compared with 50 percent of those in the same income range who had health insurance, and 56 percent of higher-income adults. Only about one-third – or 32 percent – of low-income uninsured women ages 40 to 64 had received a mammogram, compared with two-thirds – or 66 percent – of low-income women with health insurance and three-fourths – or 74 percent – of higher-income women.

Karen Davis, president of the Commonwealth Fund, said during the media briefing that these statistics are concerning, considering detection of breast and colon cancer at an early stage can make a significant difference in mortality.

Low- and moderate-income adults without insurance were also more likely than those in the same income bracket with health coverage to visit the emergency room because they needed a prescription – 50 percent versus 35 percent – and because they did not have a regular doctor – 41 percent versus 16 percent. Forty percent of uninsured low- and moderate income adults also said they visited the ER because other options were unaffordable.

If you take Excedrin, NoDoz, Bufferin or Gas-X Prevention or if you know you have any of these over-the-counter medications in your home, the U.S. Food and Drug Administration is advising that you dispose of these products as soon as possible.

Drug manufacturer Novartis Consumer Health, Inc. said recently that it is voluntarily recalling bottles of Excedrin and NoDoz products with expiration dates of Dec. 20, 2014, or earlier as well as Bufferin and Gas-X Prevention products with expiration dates of Dec. 20, 2013, or earlier in the United States.

Excedrin is most often used for headaches, including migraines, and Bufferin, which contains aspirin, is a painkiller. NoDoz is an alertness aid caffeine caplet.

Novartis said it is taking this action as a precautionary measure. According to the FDA, the agency received reports of chipped and broken pills and inconsistent bottle packaging clearance practices at the company’s Nebraska facility, which could result in the bottles containing foreign tablets, caplets, or capsules.

Mixing of different products in the same bottle could result in consumers taking the incorrect product and receiving a higher or lower strength than intended or receiving an unintended ingredient. This could potentially result in overdose, interaction with other medications a consumer may be taking, or an allergic reaction if the consumer is allergic to the unintended ingredient. Novartis said it is currently not aware of adverse events reported with the issues leading to the recall.

These over-the-counter products were distributed nationwide to wholesalers and retailers. Novartis said it is notifying its distributors and customers and is arranging for return of all recalled products.

Consumers that have the product or products being recalled should stop using the medication and contact the Novartis Consumer Relationship Center at 1-888-477-2403 – available Monday through Friday, 9 a.m. to 8 p.m. EST – for information on how to return the affected products and receive a full refund.

For more detailed information, consumers can visit www.novartisOTC.com. Consumers should contact their physician or healthcare provider if they have experienced any problems that may be related to taking or using these drug products.

Adverse events that may be related to the use of these products may be reported to FDA’s MedWatch Adverse Event Reporting Program either online at www.fda.gov/medwatch/report.htm or by fax at 1-800-FDA-0178.

Credit card companies, airlines and hotels all have customer loyalty programs. Maybe it was only a matter of time before hospitals got in on the act.

A growing number of hospitals are seeking to attract new patients and keep existing ones by offering them an array of perks, from free parking and gift-shop discounts to wellness seminars and health screenings. Some of the most popular programs are social mixers that have nothing to do with health care. Field trip to a casino, anyone?

It's all part of a changing competitive environment in which hospitals market themselves directly to patients, who have begun to take a much more active role in choosing their health-care providers -- and are on the hook for a greater share of the costs.

Before managed care, hospitals focused more on appealing to physicians with new and advanced medical technologies, experts say. Physicians, it was thought, would bring in the patients.

Changes in health-care policies are giving hospitals added incentive to develop relationships with patients. Under the 2010 health-care overhaul, hospitals with higher than expected 30-day readmission rates for heart attack, heart failure and pneumonia will face financial penalties starting this year. The number of conditions subject to penalty will be expanded in subsequent years, and hospitals can help themselves by working with patients before they land in the hospital with an acute problem.

"Hospitals will have an expanding share of risk in their patient populations going forward," says Tony Paquin, chief executive of Paquin Healthcare, an Orlando consulting and technology firm that has worked with more than 150 hospitals to develop loyalty programs. "Health-care providers are just starting to figure out that they need to develop patient relationships if they're going to improve their health long term."

Botsford Hospital in Farmington Hills, Mich., started issuing free "Very Important Patient" cards in 2010. The program got its start as a referral service to link potential patients with Botsford doctors. The cards entitle VIP members to free parking and a 10 percent discount on nonprescription drugs at the outpatient pharmacy and the gift shop, says Lynn Anderson, marketing and public relations manager at the 330-bed hospital in the Detroit suburb. VIP members can also get discounts at restaurants and service establishments such as an oil-change garage.

The program, which has more than 900 members, is open to anyone in the community. In addition to financial perks, it offers regular health education seminars on such topics as hip replacements, back problems and acid-reflux disease, says Anderson.

"This is a way to get a mailing list and send them information," she says. "In this day and age, with so much competition, you need to make a connection with patients."

Luanne Dunigan, a 78-year-old retired nurse, signed up for Botsford's VIP program after receiving a letter from the hospital. Dunigan had never been a patient at Botsford Hospital, but she told her grandson to take her to the emergency department there twice recently, once when she was having trouble swallowing and again when she had chest pain.

The VIP program was a factor in her decision, she says, and she was pleased with the care she received. "It was the best hospitalization I ever had."

Since becoming a VIP member, Dunigan has parked for free and received discounts at the gift shop when visiting a friend.

She's also looking forward to taking advantage of another perk offered through the program: social events. VIP members get a free one-year membership in Generations, a Botsford Hospital program for people 50 and older that organizes outings, including trips to the symphony and theater as well as luncheons with lectures on health and other topics. Membership is normally $15 annually. Dunigan says she's especially looking forward to taking one of the overnight trips to a casino in Canada. "Now that I've retired, I plan to take advantage of those trips," she says.

One of the most popular loyalty program events sponsored by Baystate Health, a four-hospital system in Springfield, Mass., is the annual "Spirit of Women" conference, says Tracy Whitley, manager of loyalty programs. Up to 400 people attend the event, now in its 14^th year, which showcases a nationally recognized motivational speaker. The conference also gives hospital officials a chance to showcase services they offer related to women, such as the comprehensive breast cancer center and urogynecology, she says.

Baystate also offers a range of free educational health programs aimed at women and at people age 55 and older. "We like to build relationships with all people, and hopefully they will use our services in the future," says Whitley.

These sorts of marketing activities make sense, say experts. "Customers will go to a provider and judge the experience based on things that they can understand: good food, ease of parking, attentiveness, nice sheets," says Paquin.

John Romley, a health economist at the University of Southern California who co-authored an article in the New England Journal of Medicine about the increasing importance of amenities in patient care, concurs. "Patient preferences about where they receive care seem to turn on creature comforts and amenities," he says, rather than on health-care-related measures such as complication or infection rates.

While there are no data to show that loyalty programs encourage patients to get unnecessary care, Romley says these marketing efforts are in some ways analogous to drugmakers' controversial advertising that "reach[es] out directly to consumers in order to have them drive the medical decision-making to a degree and have them demand the expensive drug," he says.

As for those casino trips? "It has nothing to do with what the hospital does," he says. "It's not necessarily a bad thing, but it's rather indirect."

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