By Melanie Evans
ModernHealthcare.com
January 4, 2011

Health insurers’ outlook continues to be negative as the sector faces new regulations, heightened political pressure and a weak economy, which are expected to squeeze earnings, one major ratings agency said.

Moody’s Investors Service said in a report that insurance provisions of the Patient Protection and Affordable Care Act that go into effect this year could limit insurers’ income. Analysts described 2011 “as a transition year” for insurers as companies grapple with new medical-loss ratio regulations, which require 85% of large group premiums and 80% of small group and individual premiums to be spent on patient care.

Flat Medicare Advantage reimbursement levels for 2011, to be followed by cuts next year, could squeeze insurers’ margins, the report said. Insurers have moved to diversify to increase revenue and income not affected by changes under the reform law, analysts said. The sector also faces greater oversight and political pressure regarding insurers’ premium increases.

Insurers also face threats to enrollment from the economy, according to the report. The weak job market and possible further layoffs in the public sector this year could leave more households without employment, the source of health insurance for many, the report said. Struggling employers and households may not be willing or able to pay for care even as providers seek pay increases to increase revenue.

http://www.modernhealthcare.com/article/20110104/NEWS/301049965/-1#

And…

US Healthcare Insurers: Outlook Remains Negative

Moody’s Investor Service
December 29, 2010

…Despite better than expected results in 2010, Moody’s has maintained its negative outlook for the U.S. healthcare insurance sector due to regulatory, political, and economic threats that combine to place downward pressure on future earnings. Our expectations for 2011 for the sector as a whole include lower earnings, flat-to-low membership growth, and strategies increasingly focused on diversification. The negative sector outlook represents our view of credit conditions facing health insurers over the next 12 to 18 months; it provides a framework against which to consider issuer-specific ratings and research. 1. Regulatory Issues ¡ The healthcare reform law passed in early 2010, has already imposed a number of challenges for health insurers. During 2010, most changes required insurers to provide additional benefits while allowing them to adjust premiums appropriately. However, in 2011, two key provisions of the law — minimum medical loss ratio (MLR) regulations and changes to Medicare Advantage…

The remainder of this 9 page report can be purchased for $550.00 at this link:
http://moodys.alacra.com/research/moodys-global-credit-research—PBC_129845

Comment: 

By Don McCanne, MD

We hear much about the private health insurance industry from Health and Human Services (HHS) and from America’s Health Insurance Plans (AHIP) and the private insurers themselves. This report is of interest because it provides a perspective on for-profit health insurers from a consulting firm for investors.

Although the regulatory changes that the insurance industry faces as a result of the Patient Protection and Affordable Care Act bring bad news to investors, in a sense this is good news for patients because some of the greed has been squeezed out of the system. Moody’s seems to be an expert on greed since they charge $550.00 for a 9 page report that apparently only tells us what we already knew. (I must confess that I made an exception in not reading the full report that was used as the source of today’s quote since I couldn’t bring myself to pay that fee.)

We could have had better news. The savings that is good news for patients is only minuscule when you consider the much larger amount that we could have saved by changing to a single payer national health program – an improved Medicare for all.

Outlook negative for insurers: Moody’s

By Melanie Evans
ModernHealthcare.com
January 4, 2011

Health insurers’ outlook continues to be negative as the sector faces new regulations, heightened political pressure and a weak economy, which are expected to squeeze earnings, one major ratings agency said.

Moody’s Investors Service said in a report that insurance provisions of the Patient Protection and Affordable Care Act that go into effect this year could limit insurers’ income. Analysts described 2011 “as a transition year” for insurers as companies grapple with new medical-loss ratio regulations, which require 85% of large group premiums and 80% of small group and individual premiums to be spent on patient care.

Flat Medicare Advantage reimbursement levels for 2011, to be followed by cuts next year, could squeeze insurers’ margins, the report said. Insurers have moved to diversify to increase revenue and income not affected by changes under the reform law, analysts said. The sector also faces greater oversight and political pressure regarding insurers’ premium increases.

Insurers also face threats to enrollment from the economy, according to the report. The weak job market and possible further layoffs in the public sector this year could leave more households without employment, the source of health insurance for many, the report said. Struggling employers and households may not be willing or able to pay for care even as providers seek pay increases to increase revenue.

http://www.modernhealthcare.com/article/20110104/NEWS/301049965/-1#

And…

US Healthcare Insurers: Outlook Remains Negative

Moody’s Investor Service
December 29, 2010

…Despite better than expected results in 2010, Moody’s has maintained its negative outlook for the U.S. healthcare insurance sector due to regulatory, political, and economic threats that combine to place downward pressure on future earnings. Our expectations for 2011 for the sector as a whole include lower earnings, flat-to-low membership growth, and strategies increasingly focused on diversification. The negative sector outlook represents our view of credit conditions facing health insurers over the next 12 to 18 months; it provides a framework against which to consider issuer-specific ratings and research. 1. Regulatory Issues ¡ The healthcare reform law passed in early 2010, has already imposed a number of challenges for health insurers. During 2010, most changes required insurers to provide additional benefits while allowing them to adjust premiums appropriately. However, in 2011, two key provisions of the law — minimum medical loss ratio (MLR) regulations and changes to Medicare Advantage…

The remainder of this 9 page report can be purchased for $550.00 at this link:
http://moodys.alacra.com/research/moodys-global-credit-research—PBC_129845

We hear much about the private health insurance industry from Health and Human Services (HHS) and from America’s Health Insurance Plans (AHIP) and the private insurers themselves. This report is of interest because it provides a perspective on for-profit health insurers from a consulting firm for investors.

Although the regulatory changes that the insurance industry faces as a result of the Patient Protection and Affordable Care Act bring bad news to investors, in a sense this is good news for patients because some of the greed has been squeezed out of the system. Moody’s seems to be an expert on greed since they charge $550.00 for a 9 page report that apparently only tells us what we already knew. (I must confess that I made an exception in not reading the full report that was used as the source of today’s quote since I couldn’t bring myself to pay that fee.)

We could have had better news. The savings that is good news for patients is only minuscule when you consider the much larger amount that we could have saved by changing to a single payer national health program – an improved Medicare for all.

Cuomo Targeting Medicaid Spending

By Jacob Gershman
The Wall Street Journal
January 4, 2011

Gov. Andrew Cuomo is aiming to reduce the state’s Medicaid spending by billions of dollars, exceeding the size of cuts to the program proposed in past years, according to individuals with knowledge of his budget.

The Cuomo administration is considering a cut of about $2.1 billion out of the state’s projected spending on Medicaid in the upcoming fiscal year. With federal matching funds, the cut comes to more than $4 billion.

http://online.wsj.com/article/SB10001424052748704111504576060280154691892.html

And…

Brown to propose broad list of budget cuts

By Kevin Yamamura
The Sacramento Bee
January 3, 2011

(Gov. Jerry Brown) will propose Medi-Cal (Medicaid) savings by requiring patients to provide co-payments for services, limiting doctor visits and reducing rates paid to health providers. In Healthy Families (CHIP), which provides subsidized care for low-income children, he wants participants to pay more in premiums and co-payments while eliminating vision care.

“These would be shocking cuts if we hadn’t seen them before, but we have seen them before,” said Anthony Wright, executive director of Health Access California. “This is what’s left to cut outside of the wholesale dismantling of core programs. These are bad cuts that will impact millions of Californians.”

http://www.sacbee.com/2011/01/03/3295079/brown-to-propose-broad-list-of.html

A substantial increase in eligibility qualification for the Medicaid program is a crucial measure in the Patient Protection and Affordable Care Act (PPACA), designed to decrease the numbers of Americans without insurance coverage. Now the newly-elected Democratic governors of the two most populous states in the nation intend to sharply reduce funding of their Medicaid programs. What does this say about the wisdom of the PPACA policy of using Medicaid to expand coverage?

Gov. Brown’s proposal to impose financial penalties for accessing care, placing caps on doctor visits, and further slashing payments in this already critically underfunded program can only be disastrous for the low-income patients enrolled.

Once again, this is not change we can believe in. We desperately need an improved Medicare that covers everyone.

By Andrew Pollack
The New York Times
January 1, 2011

With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments.

Drug companies say the plans help some patients afford medicines that they otherwise could not.

But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.

Any shift to brand-name drugs can have a big impact on health care costs.

At District Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.

For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug. Novartis’s new pill for multiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.

Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies & Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.

Drug companies cannot offer co-payment assistance for patients in federal programs like Medicare because such offers are considered an inducement to use a drug and in violation of anti-kickback laws. Some companies have responded by contributing to, or even helping to set up, charitable foundations that can provide co-payment assistance legally.

Executives at insurers and pharmacy benefit management companies say they would like to counter the cards and coupons but are not sure exactly how to do so. One problem is that the information they receive from pharmacies does not specify whether the co-pay was made by the patient or by the drug company.

“The payer doesn’t know, and the P.B.M. doesn’t know,” said F. Everett Neville, chief trade relations officer at Express Scripts, a pharmacy benefits manager. “We have no ability to stop it and no ability to prohibit it.”

http://www.nytimes.com/2011/01/02/business/02coupon.html?_r=1&pagewanted=all

Comment: 

By Don McCanne, MD

Should a health care system be designed to ensure that patients receive appropriate medications that they should have to relieve symptoms or cure disease? Of course. Yet co-payments (a dollar amount) and coinsurance (a percentage of the cost) impose on the patient financial barriers to the medications – barriers which frequently are not surmounted, and thereby may result in impaired health outcomes.

With our fragmented system of financing health care those seeking greater profits will always find another way to achieve their goals. In this instance, the pharmaceutical manufacturers have found a way to reduce or eliminate these financial barriers to their products.

In providing cost-sharing assistance to the patient, the manufacturers are not specifically removing barriers to the most appropriate products, but rather are removing barriers to their most profitable products, irrespective of whether or not they are the best choice. Since these are more expensive products, that increases the drug costs of the private insurers. Those of us paying premiums to private insurers that cover drugs are paying for these excess costs.

These practices do not require collusion with the physicians and pharmacists since their marketing practices are effective in creating a demand for their products regardless of the appropriateness.

Note that these pharmaceutical industry subsidies of co-payments and coinsurance are illegal in federal programs such as Medicare because they are the equivalent of kickbacks. If we had a Medicare program that covered everyone and eliminated the private intermediaries such as the insurers and pharmacy benefit managers, then these kickbacks wouldn’t exist. Drugs would be prescribed based strictly on appropriateness, and would be priced to provide fair profits for the pharmaceutical firms and fair costs for Medicare.

Coupons for Patients, but Higher Bills for Insurers

By Andrew Pollack
The New York Times
January 1, 2011

With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments.

Drug companies say the plans help some patients afford medicines that they otherwise could not.

But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.

Any shift to brand-name drugs can have a big impact on health care costs.

At District Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.

For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug. Novartis’s new pill for multiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.

Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies & Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.

Drug companies cannot offer co-payment assistance for patients in federal programs like Medicare because such offers are considered an inducement to use a drug and in violation of anti-kickback laws. Some companies have responded by contributing to, or even helping to set up, charitable foundations that can provide co-payment assistance legally.

Executives at insurers and pharmacy benefit management companies say they would like to counter the cards and coupons but are not sure exactly how to do so. One problem is that the information they receive from pharmacies does not specify whether the co-pay was made by the patient or by the drug company.

“The payer doesn’t know, and the P.B.M. doesn’t know,” said F. Everett Neville, chief trade relations officer at Express Scripts, a pharmacy benefits manager. “We have no ability to stop it and no ability to prohibit it.”

http://www.nytimes.com/2011/01/02/business/02coupon.html?_r=1&pagewanted=all

Should a health care system be designed to ensure that patients receive appropriate medications that they should have to relieve symptoms or cure disease? Of course. Yet co-payments (a dollar amount) and coinsurance (a percentage of the cost) impose on the patient financial barriers to the medications – barriers which frequently are not surmounted, and thereby may result in impaired health outcomes.

With our fragmented system of financing health care those seeking greater profits will always find another way to achieve their goals. In this instance, the pharmaceutical manufacturers have found a way to reduce or eliminate these financial barriers to their products.

In providing cost-sharing assistance to the patient, the manufacturers are not specifically removing barriers to the most appropriate products, but rather are removing barriers to their most profitable products, irrespective of whether or not they are the best choice. Since these are more expensive products, that increases the drug costs of the private insurers. Those of us paying premiums to private insurers that cover drugs are paying for these excess costs.

These practices do not require collusion with the physicians and pharmacists since their marketing practices are effective in creating a demand for their products regardless of the appropriateness.

Note that these pharmaceutical industry subsidies of co-payments and coinsurance are illegal in federal programs such as Medicare because they are the equivalent of kickbacks. If we had a Medicare program that covered everyone and eliminated the private intermediaries such as the insurers and pharmacy benefit managers, then these kickbacks wouldn’t exist. Drugs would be prescribed based strictly on appropriateness, and would be priced to provide fair profits for the pharmaceutical firms and fair costs for Medicare.

Editorial
The New York Times
December 29, 2010

On Dec. 22, just before they left town for the holidays, House Republican leaders released new budget rules that they intend to adopt when they assume the majority in January and will set the stage for even more budget-busting tax cuts.

The new Republican rules will gut pay-as-you-go because they require offsets only for entitlement increases, not for tax cuts.

It gets worse. The new rules mandate that entitlement-spending increases be offset by spending cuts only — and actually bar the House from raising taxes to pay for such spending.

Even worse, they direct the leader of the House Budget Committee to ignore several costs when computing the budget impact of future actions.

For example, the cost to make the Bush-era tax cuts permanent would be ignored, as would the fiscal effects of repealing the health reform law. At the same time, the new rules bar the renewal of aid for low-income working families — extended temporarily in the recent tax-cut deal — unless it is fully paid for.

http://www.nytimes.com/2010/12/30/opinion/30thu1.html

Rules draft (33 pages):
http://rules-republicans.house.gov/Media/PDF/112-Hres5-CP_xml.pdf

Comment: 

By Don McCanne, MD

Although long, the new Republican rules for the House of Representatives read somewhat like those jokes that are circulated around the Internet. When the fact sinks in that this is no joke but that these rules are very real, the inhumanity implicit in these new rules induces a feeling of despair.

Think of what these rules do for public funding of health care under the Patient Protection and Affordable Care Act. Because health insurance is too expensive and out-of-pocket costs are also unaffordable, government subsidies are necessary, but those called for in the act are inadequate. Many people who will need health care will face financial hardship unless the subsidies are increased.

Under the Republican rules, increases in these subsidies cannot be paid for by increasing taxes. Only reductions in other programs can be used. This is not unlike the prohibited act of cannibalizing one military vehicle to get another one up and running, when both vehicles are essential. Just as we have a responsibility to pay our taxes, our government has a responsibility to ensure that appropriate publicly-financed services will be there when needed, whether it’s maintaining our military vehicles, supporting transportation services in major snowstorms, or ensuring that everyone always has access to affordable health care.

Although the Republicans display a decidedly uncaring attitude toward the financing of important public services shared by most of us, they have an almost sacred devotion to protecting higher-income individuals from the need to pay their equitable share of the taxes to fund those services.

Any increases in spending for the public good must be offset by reductions in other services that would then no longer be available for the public good. Yet, under the new Republican rules, any tax reductions which would accrue primarily to the benefit of the wealthy do not have to be offset at all. Instead, those deficits are added to our debt burden and the debt burden passed on to our progeny.

Is the tax burden in the United States so great that we must sacrifice our public services while burdening ourselves with more debt simply to provide tax relief for the wealthy? The following chart provides that answer. The United States has one of the lowest tax burdens of all nations. The Republicans are catering to the rich at a great cost to the rest of us. What is really tragic is that it seems that, rather than electing representatives who care, the American voters would rather attend tea parties.

If the following OECD chart was not transmitted in this message, it can be accessed by scanning down to Chart A at this link:
http://www.oecd.org/document/35/0,3343,en_2649_37427_46661795_1_1_1_37427,00.html

Total tax ratio as percentage of GDP, 2008

Deficit Hypocrisy

Editorial
The New York Times
December 29, 2010

On Dec. 22, just before they left town for the holidays, House Republican leaders released new budget rules that they intend to adopt when they assume the majority in January and will set the stage for even more budget-busting tax cuts.

The new Republican rules will gut pay-as-you-go because they require offsets only for entitlement increases, not for tax cuts.

It gets worse. The new rules mandate that entitlement-spending increases be offset by spending cuts only — and actually bar the House from raising taxes to pay for such spending.

Even worse, they direct the leader of the House Budget Committee to ignore several costs when computing the budget impact of future actions.

For example, the cost to make the Bush-era tax cuts permanent would be ignored, as would the fiscal effects of repealing the health reform law. At the same time, the new rules bar the renewal of aid for low-income working families — extended temporarily in the recent tax-cut deal — unless it is fully paid for.

http://www.nytimes.com/2010/12/30/opinion/30thu1.html

Rules draft (33 pages):
http://rules-republicans.house.gov/Media/PDF/112-Hres5-CP_xml.pdf

Although long, the new Republican rules for the House of Representatives read somewhat like those jokes that are circulated around the Internet. When the fact sinks in that this is no joke but that these rules are very real, the inhumanity implicit in these new rules induces a feeling of despair.

Think of what these rules do for public funding of health care under the Patient Protection and Affordable Care Act. Because health insurance is too expensive and out-of-pocket costs are also unaffordable, government subsidies are necessary, but those called for in the act are inadequate. Many people who will need health care will face financial hardship unless the subsidies are increased.

Under the Republican rules, increases in these subsidies cannot be paid for by increasing taxes. Only reductions in other programs can be used. This is not unlike the prohibited act of cannibalizing one military vehicle to get another one up and running, when both vehicles are essential. Just as we have a responsibility to pay our taxes, our government has a responsibility to ensure that appropriate publicly-financed services will be there when needed, whether it’s maintaining our military vehicles, supporting transportation services in major snowstorms, or ensuring that everyone always has access to affordable health care.

Although the Republicans display a decidedly uncaring attitude toward the financing of important public services shared by most of us, they have an almost sacred devotion to protecting higher-income individuals from the need to pay their equitable share of the taxes to fund those services.

Any increases in spending for the public good must be offset by reductions in other services that would then no longer be available for the public good. Yet, under the new Republican rules, any tax reductions which would accrue primarily to the benefit of the wealthy do not have to be offset at all. Instead, those deficits are added to our debt burden and the debt burden passed on to our progeny.

Is the tax burden in the United States so great that we must sacrifice our public services while burdening ourselves with more debt simply to provide tax relief for the wealthy? The following chart provides that answer. The United States has one of the lowest tax burdens of all nations. The Republicans are catering to the rich at a great cost to the rest of us. What is really tragic is that it seems that, rather than electing representatives who care, the American voters would rather attend tea parties.

If the following OECD chart was not transmitted in this message, it can be accessed by scanning down to Chart A at this link:
http://www.oecd.org/document/35/0,3343,en_2649_37427_46661795_1_1_1_3742…

Total tax ratio as percentage of GDP, 2008