America’s Health Insurance Plans (AHIP)
The “Patient Protection and Affordable Care Act” (PPACA) requires health plans, beginning in 2011, to meet a medical loss ratio (MLR) requirement of 80 percent in the individual and small group markets and 85 percent in the large group market. This means that plans must spend a specified percentage of premium revenue on either reimbursement for clinical services provided to enrollees or “activities that improve health care quality.”
Ensure That Existing Efforts to Improve Quality are Allowed to Continue and New Initiatives to Support the Goals of PPACA are Not Discouraged
(Examples: nurse care managers, maternity managed care programs, and imaging managed care programs, as programs that improve quality)
Recognize That Quality Improvement Efforts Will Be Advanced By ICD-10 Implementation
The startup costs associated with implementing the International Classification of Diseases 10 classification system (ICD-10) by 2013 should be defined as an “activity that improves health care quality.”
ICD-10 is a quality, not a claims payment, initiative.
Include Fraud Prevention and Detection Activities that Improve Quality
The definition of “activities that improve health care quality” should include the expenses health plans are required to make for fraud prevention activities.
Implement a Transition Plan to Maximize Consumer Choice
PPACA provides for the implementation of comprehensive insurance market reforms in 2014, including the creation of state health insurance exchanges. Until that time, consumers in the individual market will rely on brokers to review their insurance options and consider which ones best suit their needs. For health plans, four-fifths of the individual market will remain medically underwritten, guided by the rules and regulations in each state. A transition policy is needed to move from the current system to the new system that will be created in 2014 and to allow individuals to maintain their coverage.
The NAIC (National Association of Insurance Commissioners) is charged with the responsibility to develop MLR methodologies that take into account special circumstances. This means that Congress intended for the NAIC to exercise its expertise to make adjustments to the MLR to ensure that consumers are not harmed and that competition is not decreased.
By Don McCanne, MD
In what might be perceived as private insurer chicanery, the industry’s lobby organization, AHIP, is capitalizing on phrasing in the Patient Protection and Affordable Care Act that defines the minimum percent of benefits that the insurers must pay out (medical loss ratio or MLR) as including not only reimbursement for clinical services but also for “activities that improve health care quality.”
Thus any of their administrative functions that they can pass off as improvements in quality will not apply to the 15 percent (large group) or 20 percent (individual or small group) caps on administrative spending. That allows the industry to perpetuate its pattern of profound administrative excesses and very high profits (outrageously high when considered as a percentage of their actual product – the administrative services that they are selling us).
In this report, what are they trying to pass off as quality? 1) Intrusive care managers who are employed to save money. 2) Implementation of diagnostic codes used for claims payments. 3) Administrative functions to detect fraud. 4) Perpetuating medical underwriting during the transition to cover “special circumstances” to ensure that “consumers are not harmed and that competition is not decreased.” That’s code for perpetuating the perversities of adverse selection.
The impact of this relabeling of administrative services as quality improvements is to allow the insurers to retain a greater percentage of the premium dollars for their own intrinsic purposes. The consumer pays for this either through higher premiums or decreased health care benefits.
An extremely important unintended consequence of fixed medical loss ratios has been mentioned here before, but seems to have escaped the mainstream media, so it is being repeated: Once the MLR rules are established, the primary method by which insurers can increase the services they sell us, while increasing their profits, is by increasing gross revenues, since they are guaranteed a fixed percentage of those revenues. The most effective way to increase gross revenues is to increase the amount of health care services authorized and paid for.
If the insurers change provider incentives to double the amount of health care that is being delivered, they can double their own total revenues, keeping even more as profit because of the smaller marginal administrative costs of paying for more care. This incentive of the insurers to increase total health care spending is the exact opposite of the reform goal of slowing future health care cost increases
All of this is good business. But that’s the problem. Our elected representatives chose a business model to finance health care when what we desperately need is a service model.
“Medical loss ratio” is a term that needs to be moved into the history books of failed policy concepts. Instead, we need our own public service model – an improved Medicare for everyone.