PNHP

Fixed MLR will drive health care costs higher

Fixed MLR will drive health care costs higher

Health insurers weighing options to get ahead of reform

By David S. Hilzenrath
The Washington Post
April 18, 2010

The idea was simple enough: Make sure that health insurers spend the vast majority of their revenue on patient care, instead of using it for things such as advertising, profits and executive pay.

To that end, the new health-care law says an insurer must give money back to consumers if it devotes less than 80 percent of premiums to paying medical claims and improving care. For insurers serving large groups, the target is 85 percent.

But even before the health-care overhaul was signed into law last month, one of the nation’s largest insurance companies reclassified certain expenses in a way that increased its so-called medical-loss ratio. In January, WellPoint began including under medical benefits such costs as nurse hotlines, “medical management,” and “clinical health policy,” a WellPoint executive said in a March briefing for investors.

Redefining medical spending to make the requirement more attainable is just one way insurers might adapt to the new legislation.

Similarly, the requirement that insurers devote 80 or 85 percent of premiums to medical claims and related expenses creates conflicting incentives. At its simplest, it encourages insurers to cut overhead expenses. In addition, it might give insurers pause before raising copayments and deductibles, turning away applicants with preexisting conditions, or squeezing payments to doctors and hospitals, because each of those steps would reduce medical spending and make it harder for insurers to meet the required ratios.

On the other hand, the target ratios might give them added incentive to raise premiums. By doing so, they could keep overhead and profit fixed, even as those items decline as a percentage of the premium dollar.

http://www.washingtonpost.com/wp-dyn/content/article/2010/04/17/AR2010041702658.html

And…

Implementing Health Insurance Reform: New Medical Loss Ratio Information for Policymakers and Consumers

Committee on Commerce, Science, and Transportation, Staff Report for Chairman Rockefeller
United States Senate
April 15, 2010

The goal of the medical loss ratio provision of the new health care law is to make sure that consumers get the full benefit of the health care premiums they pay insurers. As this report discusses, the insurance industry is beginning to consider the financial impact of the new minimum medical loss ratio requirements. At least one company, WellPoint, has already “reclassified” more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to “MLR shift” their previously identified administrative expenses.

As the National Association of Insurance Commissioners (NAIC) and the Department of Health and Human Services (HHS) work to implement the new statutorily required medical loss ratios, they need to make sure that insurers are spending consumers’ premium dollars on delivering health care and improving the quality of this care. Boosting medical loss ratios through creative accounting will not fulfill the new law’s goal of helping consumers realize the full value of their health insurance payments.

http://commerce.senate.gov/public/?a=Files.Serve&File_id=be0fd052-4ca6-4c12-9fb1-a5e4a09c0667

And…

American National Exec: Company to Stop Selling Individual Health Plans

insurancenewsnet.com
April 20, 2010

Two subsidiaries of American National Insurance Co. will stop selling individual medical expense health insurance plans due to the minimum medical loss ratio requirements contained in the new U.S. health reform law, an executive with the multiline insurer said.

The individual health plans are mostly high-deductible, major medical products that are a small part of the corporation’s overall business, he said. They comprise about one-third of American National’s total health sales a year.

The decision to stop new sales was made “after careful consideration of the recent health care legislation and based on the knowledge that the companies’ individual medical expense plans will not meet the requirements” of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, the company said.

http://insurancenewsnet.com/article.aspx?id=181490&type=newswires

Comment: 

By Don McCanne, MD

Although this concept has been touched upon in previous qotd messages, it is important that we clearly understand that the newly enacted medical loss ratio (MLR) requirements provide insurers with an incentive to further drive up health care costs.

How could that be? The intent of placing minimum limits on the medical loss ratio (the percentage of premiums spent on actual health care) was to limit the maximum percentage of premium dollars spent on administrative costs and profits. When the administrative costs exceed the permissible limits, the insurers, it was suggested, would find administrative efficiencies in their own operations, thereby helping to control overall spending. But since administrative services are the product that they are selling us, why would they want to pare back their own business?

Rather than achieving compliance with the medical loss ratio by reducing their own product, doesn’t it make much more sense from a business perspective to increase the amount of medical services being paid for, thereby achieving compliance with the ratio without any reduction in their own product? Of course it does.

One way to do that is to reclassify as health care as much as possible of the administrative services that they provide. As the Senate report indicates, WellPoint has already reclassified more than half a billion dollars of administrative expenses as medical expenses. This has a double accounting advantage on the ratio since it both reduces the administrative component while increasing the health care component.

What should concern us even more is the potential impact on health care spending. The more health care that the insurers authorize, the greater the health care component of the medical loss ratio. If they can hold their administrative costs at about the same level, increasing the health care component of the ratio allows them to increase… guess what… profits!

There are two ways to increase health care spending. The insurers can approve more medical services, increasing both the frequency and intensity of services authorized. More scary is that they are also motivated to increase health care spending by simply paying higher prices!

Let’s look at an example using an $80 billion insurance fund. Once the state sets up the insurance exchanges, they will be dominated by individuals and small employers. For this market, the law will require that the insurers maintain a medical loss ratio of at least 80 percent ($64 billion must be spent on health care). If they have fixed administrative costs of 15 percent ($12 billion), they can keep 5 percent as profits ($4 billion). If they can hold their administrative costs steady (at $12 billion) while increasing health care spending by 25 percent over a couple of years (to $80 billion), and increasing their premiums by 25 percent ($80 billion insurance fund increases to $100 billion) their administrative costs decrease to 12 percent (still $12 billion).
That leaves 8 percent for profits ($8 billion, up from $4 billion). Thus they DOUBLE their profits merely by being certain that health care costs continue to spiral upwards.

For those who insist that all we need is incremental fixes to the legislation that passed, tell us how you’re going to fix this one. Private market forces will always place profits before all else. Change the rules, and they will always find another way.

Imagine instead a health care financing system with about 3 percent administrative costs, zero profits, and incentives to control excessive prices and limit the excessive growth in the frequency and intensity of non-beneficial, high-tech services and products. That’s what we would have if we enacted an improved Medicare system that covered everyone.

Fixed MLR will drive health care costs higher

Health insurers weighing options to get ahead of reform

By David S. Hilzenrath
The Washington Post
April 18, 2010
The idea was simple enough: Make sure that health insurers spend the vast majority of their revenue on patient care, instead of using it for things such as advertising, profits and executive pay.
To that end, the new health-care law says an insurer must give money back to consumers if it devotes less than 80 percent of premiums to paying medical claims and improving care. For insurers serving large groups, the target is 85 percent.
But even before the health-care overhaul was signed into law last month, one of the nation’s largest insurance companies reclassified certain expenses in a way that increased its so-called medical-loss ratio. In January, WellPoint began including under medical benefits such costs as nurse hotlines, “medical management,” and “clinical health policy,” a WellPoint executive said in a March briefing for investors.
Redefining medical spending to make the requirement more attainable is just one way insurers might adapt to the new legislation.
Similarly, the requirement that insurers devote 80 or 85 percent of premiums to medical claims and related expenses creates conflicting incentives. At its simplest, it encourages insurers to cut overhead expenses. In addition, it might give insurers pause before raising copayments and deductibles, turning away applicants with preexisting conditions, or squeezing payments to doctors and hospitals, because each of those steps would reduce medical spending and make it harder for insurers to meet the required ratios.
On the other hand, the target ratios might give them added incentive to raise premiums. By doing so, they could keep overhead and profit fixed, even as those items decline as a percentage of the premium dollar.
http://www.washingtonpost.com/wp-dyn/content/article/2010/04/17/AR2010041702658.html

And…

Implementing Health Insurance Reform: New Medical Loss Ratio Information for Policymakers and Consumers

Committee on Commerce, Science, and Transportation, Staff Report for Chairman Rockefeller
United States Senate
April 15, 2010
The goal of the medical loss ratio provision of the new health care law is to make sure that consumers get the full benefit of the health care premiums they pay insurers. As this report discusses, the insurance industry is beginning to consider the financial impact of the new minimum medical loss ratio requirements. At least one company, WellPoint, has already “reclassified” more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to “MLR shift” their previously identified administrative expenses.
As the National Association of Insurance Commissioners (NAIC) and the Department of Health and Human Services (HHS) work to implement the new statutorily required medical loss ratios, they need to make sure that insurers are spending consumers’ premium dollars on delivering health care and improving the quality of this care. Boosting medical loss ratios through creative accounting will not fulfill the new law’s goal of helping consumers realize the full value of their health insurance payments.
http://commerce.senate.gov/public/?a=Files.Serve&File_id=be0fd052-4ca6-4c12-9fb1-a5e4a09c0667

And…

American National Exec: Company to Stop Selling Individual Health Plans

insurancenewsnet.com
April 20, 2010
Two subsidiaries of American National Insurance Co. will stop selling individual medical expense health insurance plans due to the minimum medical loss ratio requirements contained in the new U.S. health reform law, an executive with the multiline insurer said.
The individual health plans are mostly high-deductible, major medical products that are a small part of the corporation’s overall business, he said. They comprise about one-third of American National’s total health sales a year.
The decision to stop new sales was made “after careful consideration of the recent health care legislation and based on the knowledge that the companies’ individual medical expense plans will not meet the requirements” of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, the company said.
http://insurancenewsnet.com/article.aspx?id=181490&type=newswires

Although this concept has been touched upon in previous qotd messages, it is important that we clearly understand that the newly enacted medical loss ratio (MLR) requirements provide insurers with an incentive to further drive up health care costs.
How could that be? The intent of placing minimum limits on the medical loss ratio (the percentage of premiums spent on actual health care) was to limit the maximum percentage of premium dollars spent on administrative costs and profits. When the administrative costs exceed the permissible limits, the insurers, it was suggested, would find administrative efficiencies in their own operations, thereby helping to control overall spending. But since administrative services are the product that they are selling us, why would they want to pare back their own business?
Rather than achieving compliance with the medical loss ratio by reducing their own product, doesn’t it make much more sense from a business perspective to increase the amount of medical services being paid for, thereby achieving compliance with the ratio without any reduction in their own product? Of course it does.
One way to do that is to reclassify as health care as much as possible of the administrative services that they provide. As the Senate report indicates, WellPoint has already reclassified more than half a billion dollars of administrative expenses as medical expenses. This has a double accounting advantage on the ratio since it both reduces the administrative component while increasing the health care component.
What should concern us even more is the potential impact on health care spending. The more health care that the insurers authorize, the greater the health care component of the medical loss ratio. If they can hold their administrative costs at about the same level, increasing the health care component of the ratio allows them to increase… guess what… profits!
There are two ways to increase health care spending. The insurers can approve more medical services, increasing both the frequency and intensity of services authorized. More scary is that they are also motivated to increase health care spending by simply paying higher prices!
Let’s look at an example using an $80 billion insurance fund. Once the state sets up the insurance exchanges, they will be dominated by individuals and small employers. For this market, the law will require that the insurers maintain a medical loss ratio of at least 80 percent ($64 billion must be spent on health care). If they have fixed administrative costs of 15 percent ($12 billion), they can keep 5 percent as profits ($4 billion). If they can hold their administrative costs steady (at $12 billion) while increasing health care spending by 25 percent over a couple of years (to $80 billion), and increasing their premiums by 25 percent ($80 billion insurance fund increases to $100 billion) their administrative costs decrease to 12 percent (still $12 billion). That leaves 8 percent for profits ($8 billion, up from $4 billion). Thus they DOUBLE their profits merely by being certain that health care costs continue to spiral upwards.
For those who insist that all we need is incremental fixes to the legislation that passed, tell us how you’re going to fix this one. Private market forces will always place profits before all else. Change the rules, and they will always find another way.
Imagine instead a health care financing system with about 3 percent administrative costs, zero profits, and incentives to control excessive prices and limit the excessive growth in the frequency and intensity of non-beneficial, high-tech services and products. That’s what we would have if we enacted an improved Medicare system that covered everyone.

Implementing Health Insurance Reform: New Medical Loss Ratio Information for Policymakers and Consumers

Click here to read the report.
 
Committee on Commerce, Science, and Transportation
Office of Oversight and Investigations

Staff Report for Chairman Rockefeller
April 15, 2010

Executive Summary

Since August 2009, the Senate Commerce Committee has been investigating how commercial insurance companies spend the billions of dollars of premiums that American consumers pay them every year for health care coverage. One of the basic financial indicators that insurers, investors, insurance commissioners, and policymakers look at to understand how premium dollars are being used is the “medical loss ratio.” This staff report provides an update on the Committee’s investigation, including a review of new 2009 medical loss ratio information that health insurers recently filed with their regulators.

The 2009 medical loss ratio results shows that there continues to be a large disparity between patient medical spending in the large group market, and spending in the individual and small group markets. According to their own data, last year the largest insurers used about 15 cents out of every large group premium dollar for administrative costs and profits, while more than 26 cents out of every premium dollar went to administrative costs and profits in the individual market.

This staff report also discusses the new minimum medical loss ratios that became law as part of the health care reform legislation President Obama signed last month. The goal of the medical loss ratio provision of the new health care law is to make sure that consumers get the full benefit of the health care premiums they pay insurers. As this report discusses, the insurance industry is beginning to consider the financial impact of the new minimum medical loss ratio requirements. At least one company, WellPoint, has already “reclassified” more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to “MLR shift” their previously identified administrative expenses.

As the National Association of Insurance Commissioners (NAIC) and the Department of Health and Human Services (HHS) work to implement the new statutorily required medical loss ratios, they need to make sure that insurers are spending consumers’ premium dollars on delivering health care and improving the quality of this care. Boosting medical loss ratios through creative accounting will not fulfill the new law’s goal of helping consumers realize the full value of their health insurance payments.

Click here to read the report.

Restrictive provider networks

Some health networks drop elite hospitals

By Liz Kowalczyk
The Boston Globe
April 17, 2010

Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals such as Massachusetts General and Brigham and Women’s — a once radical idea that is gaining traction as a way to control soaring health care costs.

Amid intense scrutiny into why health care costs in Massachusetts are climbing 7.5 percent a year, limited networks have emerged as the most immediate way to control costs.

The Group Insurance Commission (the agency that oversees health insurance for state employees) required its two largest providers — Harvard Pilgrim and Tufts Health Plan — to develop restrictive networks this spring.

(Dolores Mitchell, executive director of Group Insurance Commission) acknowledged that restricted plans could lead to problems in the market, if healthy employees migrate to cheaper plans and those with serious illness remain in more expensive open networks because they need broad access to the advanced care provided at teaching hospitals. That outcome could raise costs for individuals in the open plans, since costs would be spread among fewer employees.

http://www.boston.com/news/health/articles/2010/04/17/some_health_networks_drop_elite_hospitals/?rss_id=Boston.com+–+Health+news

Comment: 

By Don McCanne, MD

Massachusetts intends to expand the use of limited provider networks in order to slow the rise in costs. The Patient Protection and Affordable Care Act also specifically allows the use of limited provider networks for the private plans that are to be established within the state insurance exchanges. The campaign rhetoric was that patients should have choice, yet the legislation limits patient choice of hospitals and health care professionals.

Losing choice is a big price to pay for allowing each private insurer to assemble provider lists based on lowest prices, especially when that doesn’t control total costs but only shifts costs. Contrast that with a single payer that negotiates appropriate prices with every provider on behalf of all patients. Appropriate prices would be based on legitimate costs plus fair profits throughout the health care delivery system. An expanded and improved primary care system would provide a portal for access to appropriate specialized services in any appropriate institution.

How would that work for expensive academic medical centers? Institutions would negotiate global budgets with consideration of patient care, teaching, and research services, and separate budgeting for capital improvements. The patient care component should not be any more expensive than similar care provided at the community level, except for high-tech services provided exclusively by the academic center. Even those services should be priced appropriately and accessed only when clinical screening indicates that they are warranted. Patients need guidance in order to prevent inappropriate choices of non-beneficial, high-tech services.

Restrictive provider networks are simply one more perversity that we don’t need in our health care financing system.

Restrictive provider networks

Some health networks drop elite hospitals

By Liz Kowalczyk
The Boston Globe
April 17, 2010
Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals such as Massachusetts General and Brigham and Women’s — a once radical idea that is gaining traction as a way to control soaring health care costs.
Amid intense scrutiny into why health care costs in Massachusetts are climbing 7.5 percent a year, limited networks have emerged as the most immediate way to control costs.
The Group Insurance Commission (the agency that oversees health insurance for state employees) required its two largest providers — Harvard Pilgrim and Tufts Health Plan — to develop restrictive networks this spring.
(Dolores Mitchell, executive director of Group Insurance Commission) acknowledged that restricted plans could lead to problems in the market, if healthy employees migrate to cheaper plans and those with serious illness remain in more expensive open networks because they need broad access to the advanced care provided at teaching hospitals. That outcome could raise costs for individuals in the open plans, since costs would be spread among fewer employees.
http://www.boston.com/news/health/articles/2010/04/17/some_health_networks_drop_elite_hospitals/?rss_id=Boston.com+–+Health+news

Massachusetts intends to expand the use of limited provider networks in order to slow the rise in costs. The Patient Protection and Affordable Care Act also specifically allows the use of limited provider networks for the private plans that are to be established within the state insurance exchanges. The campaign rhetoric was that patients should have choice, yet the legislation limits patient choice of hospitals and health care professionals.
Losing choice is a big price to pay for allowing each private insurer to assemble provider lists based on lowest prices, especially when that doesn’t control total costs but only shifts costs. Contrast that with a single payer that negotiates appropriate prices with every provider on behalf of all patients. Appropriate prices would be based on legitimate costs plus fair profits throughout the health care delivery system. An expanded and improved primary care system would provide a portal for access to appropriate specialized services in any appropriate institution.
How would that work for expensive academic medical centers? Institutions would negotiate global budgets with consideration of patient care, teaching, and research services, and separate budgeting for capital improvements. The patient care component should not be any more expensive than similar care provided at the community level, except for high-tech services provided exclusively by the academic center. Even those services should be priced appropriately and accessed only when clinical screening indicates that they are warranted. Patients need guidance in order to prevent inappropriate choices of non-beneficial, high-tech services.
Restrictive provider networks are simply one more perversity that we don’t need in our health care financing system.

Calling on health insurers to drop fast food stock

Posted by Tiffany O’Callaghan
Time
Friday, April 16, 2010

Health insurance companies in the U.S., Canada and Europe hold nearly $1.9 billion in fast-food company stock, according to a new study from researchers at Harvard Medical School and the department of medicine at Cambridge Health Alliance. In the study, published this week in the American Journal of Public Health researchers examined major insurance companies’ stock holdings with five leading, publicly traded fast food chains: McDonald’s, Burger King, Jack in the Box, Yum! Brands (which owns KFC, Taco Bell, and others), and the Wendy’s/Arby’s Group. They found that, as of June 11, 2009, major health insurers owned $1.88 billion in fast-food stock, representing 2.2% of the companies’ total public holdings.

While some of the insurance companies have disputed the accuracy of these figures, the researchers found that U.S.-based insurance providers Prudential Financial, Massachusetts Mutual and Northwestern Mutual owned $355.5 million, $366 million and $422 million respectively in fast-food stock as of last June, with Northwestern Mutual representing the largest fast-food stock holding of any insurance company included in the study. ING, the insurance provider based in the Netherlands, held $406.1 million in these stocks. Canadian insurance provider Manulife held $146.1 million worth of fast-food stock. Those numbers, according to the study, were based on data from Yahoo! Finance from June 11 of last year.

The study authors argue that these findings show a disconcerting disregard among insurance companies for the a growing understanding of how the fast food industry is “increasingly understood to negatively impact public health.” Though they concede that fast food products can of course be consumed responsibly, the researchers emphasize that “the marketing and sale of products by fast food companies is done in a manner that undermines the public health,” and that having the very organizations that provide health insurance support these fast-food chains indicates corporate irresponsibility. As study author Dr. J. Wesley Boyd told the Wall Street Journal health blog:

“They’re profiting directly off the people who eat fast food, and if that leads to obesity or cardiovascular disease, they’ll charge you more for premiums if you have some of those conditions… They’re making money in either case.”

Health insurers should be “held to a higher standard” Boyd and colleagues argue before presenting two means of achieving that loftier standing. Insurance companies can either “divest themselves of holdings in fast food companies as well as other industries that have a clearly negative health impact,” they suggest, or they can use their ownership as leverage to force fast-food chains to adopt “practices consistent with widely accepted public healthy principles.”

The researchers concede that there are a few logical explanations for why health insurance providers might hold fast-food stock—to offset financial liability “associated with their policyholders consuming fast food,” due to a lack of understanding of the potential negative public health impact of excessive fast food consumption, or even simply due to a lack of communication between departments. Yet none of these explanations let the insurers of the hook, they argue. “If insurers are to play a greater part in the health care delivery system they ought to be held to a higher standard of corporate responsibility,” they write. “This responsibility includes aligning all o their resources—including financial investments—in ways that improve health or, at the very least, do not harm it.”

Read more: http://wellness.blogs.time.com/2010/04/16/calling-on-health-insurers-to-drop-fast-food-stock/?xid=rss-topstories#ixzz0lYeU4t00

Uninsured, Medicaid Recipients Receive Substandard Migraine Care

By Deborah Brauser
Medscape

April 15, 2010 — Uninsured patients with moderate to severe migraine are twice as likely to not receive standard care, defined as abortive and prophylactic therapy, than those with private health insurance, according to results from a national survey study by researchers from Harvard Medical School.

“Adding site of care to [our] regression model suggested that 1 mechanism for this discrepancy was the reliance of the uninsured on EDs [emergency departments], a site where standard migraine care is often omitted,” write the study authors.

In addition, they found that migraine patients with Medicaid were 50% more likely to receive substandard treatment than those with private insurance, suggesting that “access to some forms of insurance is not the same as access to adequate care.”

“The tragedy is that we know how to treat this disabling condition, but because they are uninsured or inadequately insured, millions of Americans suffer needlessly,” said senior study author Rachel Nardin, MD, assistant professor of neurology at Harvard Medical School and chief of neurology at the Cambridge Health Alliance in Massachusetts, in a release.

“Neurologists as well as all doctors need to advocate for healthcare reforms that provide clear access and appropriate care for everyone with migraine,” Dr. Nardin added to Medscape Neurology. “There is still a lot of work to be done to make our health system better for this group of patients.”

This study is published in the April 13 issue of Neurology.

Migraines Cost Employers Billions

Migraine headaches affect 18% of women and 6% of men in the United States, cause a loss of 4 to 6 workdays each year, and cost employers as much as $17 billion annually, according to the study. They add that approximately 15% of Americans are currently uninsured.

The standard of care guidelines for moderate to severe migraine from the American Academy of Neurology (AAN) recommend “a triptan or dihydroergotamine (DHE) as first line therapy, based on their superiority to nonsteroidal anti-inflammatory drugs (NSAIDS) and older migraine-specific medications such as ergotamine/caffeine,” report the study authors.

The AAN also recommends prophylactic therapy for these patients, especially if their migraines are frequent, do not respond completely to the abortive therapy, or are disabling.

For this study, the investigators sought to evaluate whether insurance status was associated with prescription of the AAN’s recommended standard migraine therapy, defined as a triptan or DHE plus 1 of the prophylactic medications listed in the AAN’s latest practice guidelines, if needed. NSAIDs were excluded as prophylactic therapy in this study.

Data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were assessed for 6814 patients and their 68.6 million visits from 1997-2007 due to migraine. These surveys, conducted by the National Center for Health Statistics, report patient visits to physicians’ offices, hospital outpatient departments, and EDs.

Less Medication Prescribed for Uninsured

Results showed that “after controlling for age, gender, race/ethnicity, geographic location, and year, [migraineurs] with no insurance or Medicaid were significantly less likely than the privately insured to receive abortive…and prophylactic therapy,” report the study authors.

Table. Migraine Therapy by Insurance Status
Insurance Status OR (95% CI)
Abortive therapy
No Insurance 2.0 (1.3 – 3.0)
Medicaid 1.6 (1.1 – 2.3)
Prophylactic therapy
No insurance 2.0 (1.3 – 2.9)
Medicaid 1.5 (1.0 – 2.1)

CI = confidence interval; OR = odds ratio for failure to receive medication

A total of 7.9% of the 68.6 million migraine visits were by those without insurance, and 34.1% of these patients received all of their migraine care at EDs compared with 13.2% of those with private insurance.

Controlling for site of care showed that the odds ratio (OR) for not receiving standard care was significantly greater for ED visits vs visits to physicians’ offices (OR, 4.8 vs 1.0 for abortive therapy; OR, 8.7 vs 1.0 for prophylactic therapy). There was also a significant trend for substandard care in EDs for the uninsured.

Finally, patients older than 65 years were associated with failure to receive abortive therapies (OR, 3.8), “perhaps because contraindications to triptans are common in the elderly,” the study authors note, whereas Hispanics (OR, 2.1) and those in the Midwest (OR, 1.5) were less likely to receive prophylactic therapy.

Study limitations include that the treating clinician made migraine diagnoses without independent verification, no data existed on migration durations, and the definition of prophylactic medication was broad and may have been used for indications other than migraine.

Our study strongly suggests that absent or inadequate insurance and site of care are the major drivers for substandard migraine care.

“Overall, our study strongly suggests that absent or inadequate insurance and site of care are the major drivers for substandard migraine care,” said Dr. Nardin.

“While the results for the noninsured weren’t unexpected, what was a little more surprising was what we found if you had Medicaid, which is one of the main ways that Americans are going to get insurance in the new health bill,” she noted. “Many, many private doctors don’t take Medicaid insurance because it’s used poorly. So we’re basically forcing these patients to go to emergency rooms, which is just not good for them and not good for our health system overall.

“A study like ours is a good reminder to doctors that when we want to take care of patients with migraine, it’s just as important to think about the larger health system as it is to understand what the best drugs are,” concluded Dr. Nardin. “If these patients can’t get in to see us, we can’t treat this neurologic condition that causes a lot of personal pain and suffering as well as a huge cost to society.”

All Patients With Migraine Deserve to Be Treated

“These findings were not surprising, and I could have predicted the results,” said Stephen Silberstein, MD, professor of neurology and director of the headache clinic at Thomas Jefferson University in Philadelphia, Pennsylvania, past president of the American Headache Society, and head of the Headache Research Group for the World Federation of Neurology, during an interview with Medscape Neurology.

“If you have no insurance or bad insurance and don’t see a doctor [for this disorder], you get second-rate care. [The investigators] proved what we all believe,” said Dr. Silberstein, who was not associated with this study.

“Migraine is one of the most major, disabling disorders out there, and we currently have a standard of care,” he added. “Maybe Medicaid carriers should be forced to follow the same standard of care or be punished. In fact, we’re working on that now. We’re trying to work on standards of care for migraines for insurance companies.”

When asked if EDs should be forced to follow the same standard of care guidelines, Dr. Silberstein said that that’s a different scenario. “It’s very different when someone comes into the [ED] with a severe headache. Basically, they see these patients 1 time, and it’s not safe to start an acute and preventative program without follow-up.”

“I think the fundamental issue is not that the [ED] is doing something wrong, it’s that the patients have to go there for acute care. That’s not the place to have headache treated.”

“I think it’s important for neurologists to realize that migraine is underdiagnosed and undertreated,” summarized Dr. Silberstein. “If a patient has a disabling headache, we should th
ink migraine and treat it with the best medicines available. Overall, I just think we need to demand that all patients with disabling pain disorders get respect and get appropriately treated.”

Dr. Nardin reports having received honoraria for lectures not funded by industry, serves on the editorial board of Muscle & Nerve, and has received royalties from publications in UpToDate. Disclosures for the coauthors are listed in the article. Dr. Silberstein has disclosed no relevant financial relationships.

Neurology. 2010;74:1178-1183.

http://www.medscape.com/viewarticle/720295

UnitedHealth CEO reaps nearly $100 million from stock options

UnitedHealth CEO reaps nearly $100 million from stock options

By David S. Hilzenrath
The Washington Post
April 16, 2010

The chief executive of UnitedHealth Group, one of the nation’s largest health insurers, reaped almost $100 million from exercising stock options last year, the company reported Thursday.

Stephen J. Hemsley exercised 4.9 million options in February 2009 at a gain of $98.6 million, the company said in a regulatory filing. The options were awarded almost a decade earlier.

According to measurement standards used by the Securities and Exchange Commission, Hemsley’s compensation for 2009 was a less stratospheric $8.9 million, up from $3.2 million in 2008. The 2009 total included a salary of $1.3 million, which was unchanged from the previous year, and a cash bonus of $2 million, up from $1.8 million the year before. It also included $5.6 million attributed to stock-related awards.

The compensation committee of UnitedHealth’s board believed that Hemsley’s 2009 compensation package “was appropriate to recognize Mr. Hemsley’s overall leadership in positioning the Company for long-term success in a very difficult overall economic environment,” UnitedHealth said in the report filed with the SEC Thursday.

The committee credited Hemsley with “enhancing the Company’s reputation, ethical culture and tone at the top.”

“Although Mr. Hemsley’s total compensation is below the median as compared to other CEOs in the Company’s peer groups, the Compensation Committee and Mr. Hemsley agree that it is sufficient to motivate and retain him,” the company reported.

http://www.washingtonpost.com/wp-dyn/content/article/2010/04/16/AR2010041601191.html

Comment:

By Don McCanne, MD

Although the compensation of UnitedHealth’s Stephen Hemsley may be enough to motivate and retain him, it is difficult to see how it affirms his role in enhancing an ethical culture at the top. The behavior for which he is being rewarded is precisely what should have been eliminated with the recently enacted health care financing legislation.

The ethical culture we should have would be one in which our health care dollars would be used to ensure that everyone receives the health care that they need. Instead, President Obama and Congress have ensured that Mr. Hemsley and his ilk will continue to be richly rewarded (for what?), while tens of millions are left without coverage, and the rest of us will have difficulties paying our premiums and our-of-pocket expenses.

UnitedHealth’s version of “ethical culture.” What BS!

Frontline Fronts for Corporations, Not the Public

By Margaret Flowers, M.D.
Counterpunch, Weekend Edition, April 16-18, 2010

It was with a sense of déjà vu that I watched the latest Frontline documentary about health care. “Obama’s Deal” endeavored to reveal the significant influence of health industry dollars on our political process; however, as in Frontline’s “Sick Around America,” the producers did a disservice by the failure to educate the public about the bigger picture of the health care situation in this nation and the range of possible solutions.

Curiously, just as it was in the health “debate,” single payer, improved Medicare for All, was also excluded from the film. The major point of the influence of health industry dollars on the reform process which should have been mentioned is that these dollars were spent in order to restrict the debate and protect industry profits. The lucrative status quo would have been threatened if single payer had been openly discussed because a publicly-financed national health program can provide high quality universal health care and control health care costs, something that a private insurance based system cannot accomplish.

After watching this film, viewers would have no idea that single payer exists or know that there is a strong movement for it. Considering that there have been attempts to push for a national health program for over 100 years in this nation and that, because of a strong grassroots movement, single payer legislation was nearly introduced on the floor of the House in November and was actually introduced on the floor of the Senate for the first time in this nation last December, the omission appears to be intentional.

Those of us in the single payer movement are accustomed to being censored by the corporate media. The reason for our exclusion is known: health insurance and pharmaceutical corporations advertise heavily on these airwaves and wield considerable power over the programming. This was described clearly by Fairness and Accuracy in Reporting’s August 2009 piece titled “Single-Payer & Interlocking Directorates: The corporate ties between insurers and media companies” by Kate Murphy.

The producers at Frontline carefully cut single payer out of the film. When the host, Mr. Kirk, interviewed me for “Obama’s Deal,” we spoke extensively of the single payer movement and my arrest with other single payer advocates in the Senate Finance Committee last May. However, our action in Senate Finance was then misidentified as “those on the left” who led a “counterattack” because of “liberal outrage” at being excluded. This occurred despite an email exchange following the release of the preview in which I specifically requested that the producers identify that we are a nonpartisan group fighting for single payer: a health reform model based on evidence of what is effective here and abroad and on health policy principles. This mischaracterization unfortunately mirrors the way in which the health industry has portrayed the single payer movement (verified by Wendell Potter, a former Cigna executive).

“Obama’s Deal” contained a segment on those who oppose health reform, but nowhere were single payer advocates given a chance to explain their proposal or motivations. Neither was it noted that the hatred and fear seen at the summer Town Halls and that factored in the election of Scott Brown were assisted by the stealth organizing efforts of ultra-conservative Dick Armey of FreedomWorks and others.

We have the resources in this nation to achieve the same high quality health outcomes and health security that exist in other advanced nations. One reason for our failure is the intentional misinformation and omission of information in corporate media. Our public media does a disservice by leaving out the full picture of our broken political process, its effect on the health and economic wellbeing of our people and the truth of what we can achieve.

Margaret Flowers, MD is a pediatrician who serves as the Congressional Fellow for Physicians for National Health Program.

http://www.counterpunch.org/flowers04162010.html

Health Insurers Hedge Bets With Fast Food Stock

Researchers Lambast Health Insurance Companies; Not All Convinced Investment Is Irresponsible

By TODD NEALE
MedPage Today Staff Writer
ABC News, April 16, 2010

Companies providing life and health insurance owned $1.9 billion worth of stock in the fast-food industry as of June 11, 2009, researchers reported online in the American Journal of Public Health.

The investments were in the five largest fast-food corporations — Jack in the Box, McDonald’s, Burger King, Yum! Brands (KFC, Taco Bell, Pizza Hut, and others), and Wendy’s/Arby’s, according to J. Wesley Boyd of Harvard Medical School and Cambridge Health Alliance in Massachusetts and colleagues.

“The insurance industry, ostensibly, appears to be concerned about people’s health and well-being,” Boyd said.

But, he said, “If the insurance industry is willing to invest in products known to be harmful and/or kill people then, prima facie, this is not an industry that actually cares about health and well-being.”

Although Boyd acknowledged that fast food can be consumed responsibly, he said the aggregate evidence points toward a negative effect on public health.

“We argue that insurers ought to be held to a higher standard of corporate responsibility,” he and his co-authors wrote in their paper.

All of the study authors are members — and two are co-founders — of Physicians for a National Health Program, a nonprofit organization advocating for universal, single-payer national health insurance.

“PNHP opposes for-profit control, and especially corporate control, of the health system and favors democratic control, public administration, and single-payer financing,” the organization’s mission statement reads.

Boyd said that the passage of healthcare reform makes the issue of owning stock in fast-food companies especially important.

“The health insurance industry is going to have a much bigger stake in providing healthcare, and what we’re doing in our paper is reminding people that [the industry’s] primary interests are in earning money and generating profit, not in insuring people’s health,” he said.

Pauline Rosenau, a professor of management, policy, and community health at the University of Texas School of Public Health, said the investment strategy of these insurance companies is not ethical.

“They are placing themselves in a situation of substantial conflict of interest — especially starting in 2014,” she said.

“Starting in 2014, insurers will have an even greater incentive to encourage their customers to pursue healthy food choices,” she continued. “However, this is only with respect to their own customers, not those insured by other companies. As long as insurers are largely private, for-profit entities, they are unlikely to identify with a public health orientation.”

To determine the extent to which insurance companies invested in the fast-food industry, Boyd and his colleagues analyzed shareholder data from the Icarus database, which contains information from Securities and Exchange Commission filings and reports from news agencies.

Their data were “vetted during the peer-review process by outside referees,” according to a spokesperson for the American Public Health Association, which publishes the American Journal of Public Health.

The $1.9 billion worth of stock in the five leading fast food companies represented 2.2 percent of the total market capitalization of those companies on June 11, 2009.

Most of the investments ($1.2 billion) were in McDonald’s, followed by Yum! Brands ($404.2 million), Burger King ($165.5 million), Jack in the Box ($120 million), and Wendy’s/Arby’s ($15 million).

The insurer investing the most in fast food — $422.2 million — was Northwestern Mutual, which offers life, disability, and long-term care insurance.

Next highest at $406.1 million was ING, a Dutch investment company selling life and disability insurance.

Massachusetts Mutual, which offers life, disability, and long-term care insurance, and Prudential Financial, which sells life insurance and long-term disability coverage, ranked third and fourth at $366.5 million and $355.5 million, respectively.

At first glance, it would appear that there is an inconsistency with insurance companies that have an interest in protecting health investing in the fast-food industry, although Boyd said that it makes sense financially.

“They’re hedging their bets,” he said. “First of all, they’re making money by directly investing in fast food, and, secondly, they’re making money by often charging higher premiums to people who’ve eaten a little too much fast food and are obese, have diabetes, cardiovascular disease, high blood pressure, etc.”

He said that he would like to see insurance companies sell their stakes in the fast-food companies.

“But if they don’t divest, at a minimum they could use their position as owners of fast food to insist on higher quality products, lower calories, [and] better information about how many calories are in different foods,” he said.

Dr. David Orentlicher of the William S. and Christine S. Hall Center for Law and Health at Indiana University agreed that insurers should be held to a higher standard of corporate responsibility.

“That said,” he said, “it is very difficult in a capitalist society to expect people or companies to act against their self-interest. If we want people to act responsibly, we have to create financial incentives for them to do so.”

Theodore Marmor, a professor emeritus of public policy and management at Yale School of Management, did not agree that health and life insurers should be held to a different standard than other companies.

“I think this is a foolish approach to improving the health of the public,” Marmor said.

“It would be hard to find any corporation that did not have some effect on the public’s health. Why are insurers to be held to a higher standard? We have more important worries about health insurers than improving their stock portfolios — e.g., their behavior as insurers.”

Northwestern Mutual and ING did not respond to a request for comment.

A spokesperson for Massachusetts Mutual said the reported investments were “absolutely incorrect.” He said that as of Dec. 31, the company owned about $1.4 million worth of stock in fast-food-related companies, which was “less than one-hundredth of one percent of cash and total invested assets of $86.6 billion.”

A Prudential Financial spokesperson said, “We can’t discuss specific investments within Prudential portfolios or those managed for third parties. That said, we have a fiduciary duty to manage assets in a way that provides the opportunity for consistently strong investment performance to our individual and institutional clients, while managing risk and investing responsibly.”

A spokesperson for America’s Health Insurance Plans (AHIP), a trade group for health insurers, said he could not comment on the investments of individual companies.

“Our industry is strongly committed to health and wellness,” he said. “Health plans have pioneered programs to promote prevention and encourage people to live healthier lifestyles.”

Copyright © 2010 ABC News Internet Ventures

http://abcnews.go.com/Health/w_DietAndFitness/health-insurance-companies-invest-billions-fast-food-stock/story?id=10392603&page=1

UnitedHealth CEO reaps nearly $100 million from stock options

UnitedHealth CEO reaps nearly $100 million from stock options

By David S. Hilzenrath
The Washington Post
April 16, 2010
The chief executive of UnitedHealth Group, one of the nation’s largest health insurers, reaped almost $100 million from exercising stock options last year, the company reported Thursday.
Stephen J. Hemsley exercised 4.9 million options in February 2009 at a gain of $98.6 million, the company said in a regulatory filing. The options were awarded almost a decade earlier.
According to measurement standards used by the Securities and Exchange Commission, Hemsley’s compensation for 2009 was a less stratospheric $8.9 million, up from $3.2 million in 2008. The 2009 total included a salary of $1.3 million, which was unchanged from the previous year, and a cash bonus of $2 million, up from $1.8 million the year before. It also included $5.6 million attributed to stock-related awards.
The compensation committee of UnitedHealth’s board believed that Hemsley’s 2009 compensation package “was appropriate to recognize Mr. Hemsley’s overall leadership in positioning the Company for long-term success in a very difficult overall economic environment,” UnitedHealth said in the report filed with the SEC Thursday.
The committee credited Hemsley with “enhancing the Company’s reputation, ethical culture and tone at the top.”
“Although Mr. Hemsley’s total compensation is below the median as compared to other CEOs in the Company’s peer groups, the Compensation Committee and Mr. Hemsley agree that it is sufficient to motivate and retain him,” the company reported.
http://www.washingtonpost.com/wp-dyn/content/article/2010/04/16/AR2010041601191.html

Although the compensation of UnitedHealth’s Stephen Hemsley may be enough to motivate and retain him, it is difficult to see how it affirms his role in enhancing an ethical culture at the top. The behavior for which he is being rewarded is precisely what should have been eliminated with the recently enacted health care financing legislation.
The ethical culture we should have would be one in which our health care dollars would be used to ensure that everyone receives the health care that they need. Instead, President Obama and Congress have ensured that Mr. Hemsley and his ilk will continue to be richly rewarded (for what?), while tens of millions are left without coverage, and the rest of us will have difficulties paying our premiums and our-of-pocket expenses.
UnitedHealth’s version of “ethical culture.” What BS!

Health, life insurers hold $1.88 billion in fast-food stocks: AJPH article

Harvard researchers say insurers put profits over health

EMBARGOED until:
April 15, 2010, 5 p.m. Eastern time    

Contact:
Arun Mohan, M.D., M.B.A.
J. Wesley Boyd, M.D., Ph.D.
Steffie Woolhandler, M.D., M.P.H.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

Just weeks after the passage of a health bill that will dramatically increase the number of Americans covered by private health insurers, Harvard researchers have detailed the extent to which life and health insurance companies are major investors in the fast-food industry.

Although fast food can be consumed responsibly, research has shown that fast-food consumption is linked to obesity and cardiovascular disease, two leading causes of death, and contributes to the poor health of children. The evidence is so compelling that as part of the new law more than 200,000 fast-food and other chain restaurants will be required to include calorie counts on their menus, including their drive-through menus.

A new article on insurance company holdings, published online in today’s [Thursday, April 15] American Journal of Public Health, shows that U.S., Canadian and European-based insurance firms hold at least $1.88 billion of investments in fast-food companies.

“These data raise questions about the opening of vast new markets for private insurers at public expense, as is poised to happen throughout the United States as a result of the recent health care overhaul,” says lead author Dr. Arun Mohan.

Among the largest owners of fast-food stock are U.S.-based Prudential Financial, Northwestern Mutual and Massachusetts Mutual Life Insurance Company, and European-based ING.

U.S.-based Northwestern Mutual and Massachusetts Mutual Life Insurance Company both offer life insurance as well as disability and long-term care insurance. Northwestern Mutual owns $422.2 million of fast-food stock, with $318.1 million of McDonald’s. Mass Mutual owns $366.5 million of fast-food stock, including $267.2 in McDonald’s.

Holland-based ING, an investment firm that also offers life and disability insurance, has total fast-food holdings of $406.1 million, including $12.3 million in Jack in the Box, $311 million in McDonald’s, and $82.1 million in Yum! Brands (owner of Pizza Hut, KFC and Taco Bell) stock.

New Jersey-based Prudential Financial Inc. sells life insurance and long-term disability coverage. With total fast-food holdings of $355.5 million, Prudential Financial owns $197.2 of stock in McDonald’s and also has significant stakes in Burger King, Jack-in-the-Box, and Yum! Brands.

The researchers also itemize the fast-food holdings of London-based Prudential Plc, U.K.-based Standard Life, U.S.-based New York Life, Scotland-based Guardian Life, Canada-based Manulife and Canada-based Sun Life. (See table; all data current as of June 11, 2009.)

“Our data illustrate the extent to which the insurance industry seeks to turn a profit above all else,” says Dr. Wesley Boyd, senior author of the study. “Safeguarding people’s health and well-being take a back seat to making money.”

Mohan, Boyd and their co-authors, Drs. Danny McCormick, Steffie Woolhandler and David Himmelstein, all at the Cambridge Health Alliance and Harvard Medical School, culled their data from Icarus, a proprietary database of industrial, banking and insurance companies. Icarus draws upon Securities and Exchange Commission filings and news reports from providers like Dow Jones and Reuters. In addition, the authors obtained market capitalization data from Yahoo! Finance.

The authors write, “The health bill just enacted in the Washington will likely expand the reach of the insurance industry. Canada and Britain are also considering further privatization of health insurance. Our article highlights the tension between profit maximization and the public good these countries face in expanding the role of private health insurers. If insurers are to play a greater part in the health care delivery system they ought to be held to a higher standard of corporate responsibility.”

Several of these same researchers, all of whom are affiliated with Physicians for a National Health Program, have previously published data about the extent to which the insurance industry is invested in tobacco. They say that because private, for-profit insurers have repeatedly put their own financial gain over the public’s health, readers in the United States, Canada and Europe should be wary about insurance firms’ participation in care.

Insurance industry holdings in fast-food companies (in millions of U.S. dollars) as of June 11, 2009.

Insurance
Company		 Jack in
the Box		 McDonald’s Burger King Yum! Brands Wendy’s/
Arby’s Group		 Total
Prudential plc       80.5  
80.5
Prudential Financial 34.1 197.2 43.7 80.5  
355.5
Mass Mutual 23.1 267.2 58.8 17.4  
366.5
New York Life 2.4        
2.4
Northwestern Mutual 40.9 318.1   63.2  
422.2
Sun Life       26.8   26.8
Standard Life   63.0      
63.0
ING 12.3 311.7   82.1   406.1
Manulife   89.1   53.7 3.3
146.1
Guardian Life 7.2       9.5
16.7
MetLife         2.2 2.2
Total 120.0 1,183.3 165.5 404.2 15.0 1,888.0

“Life and Health Insurance Industry Investments in Fast Food,” Arun V. Mohan, M.D., M.B.A.; Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.; and J. Wesley Boyd, M.D., Ph.D. American Journal of Public Health, April 15, 2010.

Physicians for a National Health Program (www.pnhp.org) is an organization of 17,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.