PNHP

Is NAIC agreement on medical loss ratios in patients’ interests?

Is NAIC agreement on medical loss ratios in patients’ interests?

Commissioners OK health rate plan

By Sarah Kliff
Politico
August 17, 2010

The National Association of Insurance Commissioners approved Tuesday morning (by a unanimous vote) a preliminary outline of what insurers will be able to count as medical costs, a document necessitated by the health reform bill’s requirement that insurers spend at least 85 percent of subscriber premiums on medical costs in the large group market and 80 percent for small group and individual plans.

While insurance commissioners moved forward unanimously, familiar fault lines emerged between consumer advocates and industry over the document and how it categorizes medical spending.

“In general, we are very pleased,” said NAIC consumer advocate Timothy Jost, a professor of health policy at Washington & Lee University. “The process has been very open and participatory. We feel like our concerns have been listened to.”

“The NAIC is conducting a transparent and thorough process as it develops the [medical loss ratio] MLR definition, but the current proposal could have the unintended consequence of turning back the clock on efforts to improve patient safety, enhance the quality of care and fight fraud,” AHIP president Karen Ignagni said in a statement.

http://www.politico.com/news/stories/0810/41179.html

NAIC approved reporting form (blank):
http://www.naic.org/documents/index_health_reform_mlr_blanks_proposal.pdf

Letter from AHIP’s Karen Ignagni:
http://www.politico.com/static/PPM153_ahip_081510.html

The National Association of Insurance Commissioners (NAIC) has finally come to agreement on the reporting form that likely will be used to determine whether or not the private insurers are in compliance with the required medical loss ratios (MLRs). The agreement is being reported as a victory for health care consumers and a defeat for the private insurance industry, but this ignores the crucial overriding issue.

The debate was over how much of their administrative costs the private insurers would be able to pass off as quality improvements that could be classified as medical expenses. Such reclassifications would allow the insurers to spend more for other non-medical purposes such as marketing and profits. Much of their attempted overreach – some described in Karen Ignagni’s letter – was rejected.

This is not a victory for the health care consumer. We are still stuck with a middleman industry that has been granted the right to keep 15 to 20 percent of our premium dollars to use for their own purposes. Congress and the President rejected a model of reform – an improved Medicare for all – that would have eliminated much of this waste plus the waste of the excess administrative burden that the insurers place on physicians and hospitals. The insurers get to include the latter as medical costs, further padding their margins, but administrative waste doesn’t benefit anyone’s health.

With all of the attention being given to the details of implementing the Patient Protection and Affordable Care Act (PPACA), too many have forgotten about the fact that the financing model in PPACA is irreparably flawed and can never bring us affordable health care for everyone. Instead of frittering away our efforts in the peripheral skirmishes, we need to pull together and win this war.

Economic crises and cost sharing don't mix

The economic crisis and medical care usage

By Annamaria Lusardi, Daniel J. Schneider, Peter Tufano
National Bureau of Economic Research
Working Paper 15843
March, 2010

We use a unique, nationally representative cross-national dataset to document the reduction in individuals’ usage of routine non-emergency medical care in the midst of the economic crisis. A substantially larger fraction of Americans have reduced medical care than have individuals in Great Britain, Canada, France, and Germany, all countries with universal health care systems. At the national level, reductions in medical care are related to the degree to which individuals must pay for it, and within countries are strongly associated with exogenous shocks to wealth and employment.

http://www.nber.org/papers/w15843

Comment: 

By Don McCanne, MD

This five-nation study of the impact of the financial crisis on usage of routine medical care demonstrates that both a decline in employment and a decline in wealth are strongly associated with reductions in medical care. But once again, the United States is an outlier.

U.S. citizens pay the highest out-of-pocket amounts for health care, and therefore were two to five times more likely than Europeans to reduce their use of health care. In difficult economic times, higher cost sharing has a greater negative impact on health care access.

The Patient Protection and Affordable Care Act (PPACA) will intensify this problem because most of the subsidized private plans will have low actuarial values, requiring larger deductibles, higher coinsurance (percentage of costs paid by the patient), and higher copayments (dollar amount paid by the patient).

The health care financing system should be designed to allow individuals to have the health care that they need without exposing them to financial hardship, and that protection certainly should extend into times of economic crises.

Now that PPACA has established underinsurance as the norm, we can anticipate greater reductions in necessary care, especially during difficult economic times. Or instead we could ensure that people receive the care that they need by replacing our financing system with a single payer national health program. As voters, it’s our choice.

Economic crises and cost sharing don’t mix

The economic crisis and medical care usage

By Annamaria Lusardi, Daniel J. Schneider, Peter Tufano
National Bureau of Economic Research
Working Paper 15843
March, 2010

We use a unique, nationally representative cross-national dataset to document the reduction in individuals’ usage of routine non-emergency medical care in the midst of the economic crisis. A substantially larger fraction of Americans have reduced medical care than have individuals in Great Britain, Canada, France, and Germany, all countries with universal health care systems. At the national level, reductions in medical care are related to the degree to which individuals must pay for it, and within countries are strongly associated with exogenous shocks to wealth and employment.

http://www.nber.org/papers/w15843

Comment: 

By Don McCanne, MD

This five-nation study of the impact of the financial crisis on usage of routine medical care demonstrates that both a decline in employment and a decline in wealth are strongly associated with reductions in medical care. But once again, the United States is an outlier.

U.S. citizens pay the highest out-of-pocket amounts for health care, and therefore were two to five times more likely than Europeans to reduce their use of health care. In difficult economic times, higher cost sharing has a greater negative impact on health care access.

The Patient Protection and Affordable Care Act (PPACA) will intensify this problem because most of the subsidized private plans will have low actuarial values, requiring larger deductibles, higher coinsurance (percentage of costs paid by the patient), and higher copayments (dollar amount paid by the patient).

The health care financing system should be designed to allow individuals to have the health care that they need without exposing them to financial hardship, and that protection certainly should extend into times of economic crises.

Now that PPACA has established underinsurance as the norm, we can anticipate greater reductions in necessary care, especially during difficult economic times. Or instead we could ensure that people receive the care that they need by replacing our financing system with a single payer national health program. As voters, it’s our choice.

Economic crises and cost sharing don't mix

The economic crisis and medical care usage

By Annamaria Lusardi, Daniel J. Schneider, Peter Tufano
National Bureau of Economic Research
Working Paper 15843
March, 2010
We use a unique, nationally representative cross-national dataset to document the reduction in individuals’ usage of routine non-emergency medical care in the midst of the economic crisis. A substantially larger fraction of Americans have reduced medical care than have individuals in Great Britain, Canada, France, and Germany, all countries with universal health care systems. At the national level, reductions in medical care are related to the degree to which individuals must pay for it, and within countries are strongly associated with exogenous shocks to wealth and employment.
http://www.nber.org/papers/w15843

This five-nation study of the impact of the financial crisis on usage of routine medical care demonstrates that both a decline in employment and a decline in wealth are strongly associated with reductions in medical care. But once again, the United States is an outlier.
U.S. citizens pay the highest out-of-pocket amounts for health care, and therefore were two to five times more likely than Europeans to reduce their use of health care. In difficult economic times, higher cost sharing has a greater negative impact on health care access.
The Patient Protection and Affordable Care Act (PPACA) will intensify this problem because most of the subsidized private plans will have low actuarial values, requiring larger deductibles, higher coinsurance (percentage of costs paid by the patient), and higher copayments (dollar amount paid by the patient).
The health care financing system should be designed to allow individuals to have the health care that they need without exposing them to financial hardship, and that protection certainly should extend into times of economic crises.
Now that PPACA has established underinsurance as the norm, we can anticipate greater reductions in necessary care, especially during difficult economic times. Or instead we could ensure that people receive the care that they need by replacing our financing system with a single payer national health program. As voters, it’s our choice.

Economic crises and cost sharing don’t mix

The economic crisis and medical care usage

By Annamaria Lusardi, Daniel J. Schneider, Peter Tufano
National Bureau of Economic Research
Working Paper 15843
March, 2010

We use a unique, nationally representative cross-national dataset to document the reduction in individuals’ usage of routine non-emergency medical care in the midst of the economic crisis. A substantially larger fraction of Americans have reduced medical care than have individuals in Great Britain, Canada, France, and Germany, all countries with universal health care systems. At the national level, reductions in medical care are related to the degree to which individuals must pay for it, and within countries are strongly associated with exogenous shocks to wealth and employment.

http://www.nber.org/papers/w15843

This five-nation study of the impact of the financial crisis on usage of routine medical care demonstrates that both a decline in employment and a decline in wealth are strongly associated with reductions in medical care. But once again, the United States is an outlier.

U.S. citizens pay the highest out-of-pocket amounts for health care, and therefore were two to five times more likely than Europeans to reduce their use of health care. In difficult economic times, higher cost sharing has a greater negative impact on health care access.

The Patient Protection and Affordable Care Act (PPACA) will intensify this problem because most of the subsidized private plans will have low actuarial values, requiring larger deductibles, higher coinsurance (percentage of costs paid by the patient), and higher copayments (dollar amount paid by the patient).

The health care financing system should be designed to allow individuals to have the health care that they need without exposing them to financial hardship, and that protection certainly should extend into times of economic crises.

Now that PPACA has established underinsurance as the norm, we can anticipate greater reductions in necessary care, especially during difficult economic times. Or instead we could ensure that people receive the care that they need by replacing our financing system with a single payer national health program. As voters, it’s our choice.

Is WellPoint's business model viable?

Big and beleaguered: WellPoint's bad image

By Emily Berry
American Medical News
August 16, 2010

Thus far, WellPoint and insurance trade group America’s Health Insurance Plans have responded to criticism about rate increases with variations on the same theme: Medical costs, driven by physicians and hospitals, are rising so dramatically that insurers cannot avoid raising rates.

The argument doesn’t appear to work if WellPoint and AHIP are trying to elicit sympathy or understanding from the public or policymakers.

As it went on the defensive using studies demonstrating higher medical costs, WellPoint reduced payment for physicians in most of its markets by double-digit percentages for certain procedures, and the cuts were across all specialties, said Susanne Madden, CEO of the consulting firm Verden Group in Nyack, N.Y.

“They’ve done a spectacular job destroying customer loyalty and physician loyalty at the same time, and they’re not making any friends in government,” she said. “They don’t seem to have a grasp on the fact that if they do not have physicians as allies in some way, shape or form, they’re going to have a hard time.”

If it cannot raise rates, WellPoint — and other national insurers — will have to cut costs, experts said. This is where physicians might be affected. WellPoint is likely to cut costs by further reducing payments for hospitals and physicians and restricting networks, experts said.

http://www.ama-assn.org/amednews/2010/08/16/bisa0816.htm

Comment: 

By Don McCanne, MD

WellPoint’s phenomenal business success has been largely due to its ability to offer competitive premiums by limiting what it has had to pay out in health care benefits. Will WellPoint’s business model continue to be viable?

It has targeted its marketing to the healthy workforce and their young, healthy families, and to the portion of the individual market that can pass underwriting standards. Under the Patient Protection and Affordable Care Act (PPACA) WellPoint will no longer be able to exclude individuals with greater health care needs, neither by favorable selection nor by retroactive rescissions. Without other innovative cost controls, premium increases will be inevitable.

Under PPACA, WellPoint will also be required to provide a standard package of benefits, preventing them from reducing health care spending by cutting benefits. They will also be required to provide plans with tiered actuarial values, prohibiting them from requiring ever greater out-of-pocket cost sharing by the patient. Thus premiums will have to reflect the actual increases in health care costs.

It would be possible for WellPoint to slash reimbursement rates for physicians and hospitals, but that would be a terrible business decision wince it would risk a massive exodus from their provider networks.

It is likely that WellPoint and other insurers will establish more restrictive networks with providers who are willing to accept payment reductions in exchange for greater volume, but that loss of choice would certainly further alienate their plan subscribers, also threatening their market.

The plans may search for other innovations, including some of those in PPACA, but at this time there is little prospect that cost savings could be achieved without creating greater animosity amongst patients and providers.

To comply with PPACA, WellPoint will have to increase premiums and market primarily plans with low actuarial values of 60 or 70 percent, leaving excessive out-of-pocket costs for those with health care needs. The subsidies in PPACA are too small to prevent financial hardship, and there is little political will to expand the federal budget by increasing the subsidies.

The situation can only grow worse with time. The WellPoint model will inevitably end up in the trash heap of failed policies as it is replaced with a single payer national health program – a program that would meet the needs of patients and their health care professionals.

Is WellPoint’s business model viable?

Big and beleaguered: WellPoint’s bad image

By Emily Berry
American Medical News
August 16, 2010

Thus far, WellPoint and insurance trade group America’s Health Insurance Plans have responded to criticism about rate increases with variations on the same theme: Medical costs, driven by physicians and hospitals, are rising so dramatically that insurers cannot avoid raising rates.

The argument doesn’t appear to work if WellPoint and AHIP are trying to elicit sympathy or understanding from the public or policymakers.

As it went on the defensive using studies demonstrating higher medical costs, WellPoint reduced payment for physicians in most of its markets by double-digit percentages for certain procedures, and the cuts were across all specialties, said Susanne Madden, CEO of the consulting firm Verden Group in Nyack, N.Y.

“They’ve done a spectacular job destroying customer loyalty and physician loyalty at the same time, and they’re not making any friends in government,” she said. “They don’t seem to have a grasp on the fact that if they do not have physicians as allies in some way, shape or form, they’re going to have a hard time.”

If it cannot raise rates, WellPoint — and other national insurers — will have to cut costs, experts said. This is where physicians might be affected. WellPoint is likely to cut costs by further reducing payments for hospitals and physicians and restricting networks, experts said.

http://www.ama-assn.org/amednews/2010/08/16/bisa0816.htm

Comment: 

By Don McCanne, MD

WellPoint’s phenomenal business success has been largely due to its ability to offer competitive premiums by limiting what it has had to pay out in health care benefits. Will WellPoint’s business model continue to be viable?

It has targeted its marketing to the healthy workforce and their young, healthy families, and to the portion of the individual market that can pass underwriting standards. Under the Patient Protection and Affordable Care Act (PPACA) WellPoint will no longer be able to exclude individuals with greater health care needs, neither by favorable selection nor by retroactive rescissions. Without other innovative cost controls, premium increases will be inevitable.

Under PPACA, WellPoint will also be required to provide a standard package of benefits, preventing them from reducing health care spending by cutting benefits. They will also be required to provide plans with tiered actuarial values, prohibiting them from requiring ever greater out-of-pocket cost sharing by the patient. Thus premiums will have to reflect the actual increases in health care costs.

It would be possible for WellPoint to slash reimbursement rates for physicians and hospitals, but that would be a terrible business decision wince it would risk a massive exodus from their provider networks.

It is likely that WellPoint and other insurers will establish more restrictive networks with providers who are willing to accept payment reductions in exchange for greater volume, but that loss of choice would certainly further alienate their plan subscribers, also threatening their market.

The plans may search for other innovations, including some of those in PPACA, but at this time there is little prospect that cost savings could be achieved without creating greater animosity amongst patients and providers.

To comply with PPACA, WellPoint will have to increase premiums and market primarily plans with low actuarial values of 60 or 70 percent, leaving excessive out-of-pocket costs for those with health care needs. The subsidies in PPACA are too small to prevent financial hardship, and there is little political will to expand the federal budget by increasing the subsidies.

The situation can only grow worse with time. The WellPoint model will inevitably end up in the trash heap of failed policies as it is replaced with a single payer national health program – a program that would meet the needs of patients and their health care professionals.

My Favorite August: The 70 year Slog to Women's Suffrage

By GAIL COLLINS
The New York Times, August 13, 2010

The story in American history I most like to tell is the one about how women got the right to vote 90 years ago this month. It has everything. Adventure! Suspense! Treachery! Drunken legislators!

But, first, there was a 70-year slog.

Which is really the important part. We always need to remember that behind almost every great moment in history, there are heroic people doing really boring and frustrating things for a prolonged period of time.

That great suffragist and excellent counter, Carrie Chapman Catt, estimated that the struggle had involved 56 referendum campaigns directed at male voters, plus “480 campaigns to get Legislatures to submit suffrage amendments to voters, 47 campaigns to get constitutional conventions to write woman suffrage into state constitutions; 277 campaigns to get State party conventions to include woman suffrage planks, 30 campaigns to get presidential party campaigns to include woman suffrage planks in party platforms and 19 campaigns with 19 successive Congresses.”

And you thought health care reform was a drawn-out battle.

The great, thundering roadblock to progress was — wait for the surprise — the U.S. Senate. All through the last part of the 19th century and into the 20th, attempts to amend the U.S. Constitution ran up against a wall of conservative Southern senators.

So the women decided to win the vote by amending every single state constitution, one by one.

There were five referenda in South Dakota alone. Susan B. Anthony spent more time there than a wheat farmer. But she never lost hope. The great day was coming, she promised: “It’s coming sooner than most people think.” I love this remark even more because she made it in 1895.

Sometimes I fantasize about traveling back through time and telling my historical heroes and heroines how well things worked out in the end. I particularly enjoy the part where I find Vincent van Gogh and inform him that one of the unsold paintings piled up over in the corner will eventually go for $80 million. But I never imagine telling Susan B. Anthony how well American women are doing in the 21st century because her faith in her country and her cause was so strong that she wouldn’t be surprised.

The constitutional amendment that finally did pass Congress bore Anthony’s name. It came up before the House of Representatives in 1918 with the two-thirds votes needed for passage barely within reach. One congressman who had been in the hospital for six months had himself carted to the floor so he could support suffrage. Another, who had just broken his shoulder, refused to have it set for fear he’d be too late to be counted. Representative Frederick Hicks of New York had been at the bedside of his dying wife but left at her urging to support the cause. He provided the final, crucial vote, and then returned home for her funeral.

The Senate failed to follow suit. But Woodrow Wilson, a president who had the winning quality of being very vulnerable to nagging by women, pushed the amendment through the next year. The states started ratifying. Then things stalled just one state short of success.

Ninety years ago this month, all eyes turned to Tennessee, the only state yet to ratify with its Legislature still in session. The resolution sailed through the Tennessee Senate. As it moved on to the House, the most vigorous opposition came from the liquor industry, which was pretty sure that if women got the vote, they’d use it to pass Prohibition. Distillery lobbyists came to fight, bearing samples.

“Both suffrage and anti-suffrage men were reeling through the hall in an advanced state of intoxication,” Carrie Catt reported.

The women and their allies knew they had a one-vote margin of support in the House. Then the speaker, whom they had counted on as a “yes,” changed his mind.

(I love this moment. Women’s suffrage is tied to the railroad track and the train is bearing down fast when suddenly. …)

Suddenly, Harry Burn, the youngest member of the House, a 24-year-old “no” vote from East Tennessee, got up and announced that he had received a letter from his mother telling him to “be a good boy and help Mrs. Catt.”

“I know that a mother’s advice is always the safest for a boy to follow,” Burn said, switching sides.

We celebrate Women’s Suffrage Day on Aug. 26, which is when the amendment officially became part of the Constitution. But I like Aug. 18, which is the day that Harry Burn jumped up in the Tennessee Legislature, waving his mom’s note from home. I told the story once in Atlanta, and a woman in the audience said that when she was visiting her relatives in East Tennessee, she had gone to put a yellow rose on Harry Burn’s grave.

I got a little teary.

“Well, actually,” she added, “it was because I couldn’t find his mother.”

This article has been revised to reflect the following correction:

Correction: August 14, 2010

An earlier version of this article incorrectly stated that the House of Representatives was composed of only men in 1918. Jeannette Rankin, a female representative from Montana, served from 1917 to 1919.

http://www.nytimes.com/2010/08/14/opinion/14collins.html

My Favorite August: The 70 year Slog to Women’s Suffrage

By GAIL COLLINS
The New York Times, August 13, 2010

The story in American history I most like to tell is the one about how women got the right to vote 90 years ago this month. It has everything. Adventure! Suspense! Treachery! Drunken legislators!

But, first, there was a 70-year slog.

Which is really the important part. We always need to remember that behind almost every great moment in history, there are heroic people doing really boring and frustrating things for a prolonged period of time.

That great suffragist and excellent counter, Carrie Chapman Catt, estimated that the struggle had involved 56 referendum campaigns directed at male voters, plus “480 campaigns to get Legislatures to submit suffrage amendments to voters, 47 campaigns to get constitutional conventions to write woman suffrage into state constitutions; 277 campaigns to get State party conventions to include woman suffrage planks, 30 campaigns to get presidential party campaigns to include woman suffrage planks in party platforms and 19 campaigns with 19 successive Congresses.”

And you thought health care reform was a drawn-out battle.

The great, thundering roadblock to progress was — wait for the surprise — the U.S. Senate. All through the last part of the 19th century and into the 20th, attempts to amend the U.S. Constitution ran up against a wall of conservative Southern senators.

So the women decided to win the vote by amending every single state constitution, one by one.

There were five referenda in South Dakota alone. Susan B. Anthony spent more time there than a wheat farmer. But she never lost hope. The great day was coming, she promised: “It’s coming sooner than most people think.” I love this remark even more because she made it in 1895.

Sometimes I fantasize about traveling back through time and telling my historical heroes and heroines how well things worked out in the end. I particularly enjoy the part where I find Vincent van Gogh and inform him that one of the unsold paintings piled up over in the corner will eventually go for $80 million. But I never imagine telling Susan B. Anthony how well American women are doing in the 21st century because her faith in her country and her cause was so strong that she wouldn’t be surprised.

The constitutional amendment that finally did pass Congress bore Anthony’s name. It came up before the House of Representatives in 1918 with the two-thirds votes needed for passage barely within reach. One congressman who had been in the hospital for six months had himself carted to the floor so he could support suffrage. Another, who had just broken his shoulder, refused to have it set for fear he’d be too late to be counted. Representative Frederick Hicks of New York had been at the bedside of his dying wife but left at her urging to support the cause. He provided the final, crucial vote, and then returned home for her funeral.

The Senate failed to follow suit. But Woodrow Wilson, a president who had the winning quality of being very vulnerable to nagging by women, pushed the amendment through the next year. The states started ratifying. Then things stalled just one state short of success.

Ninety years ago this month, all eyes turned to Tennessee, the only state yet to ratify with its Legislature still in session. The resolution sailed through the Tennessee Senate. As it moved on to the House, the most vigorous opposition came from the liquor industry, which was pretty sure that if women got the vote, they’d use it to pass Prohibition. Distillery lobbyists came to fight, bearing samples.

“Both suffrage and anti-suffrage men were reeling through the hall in an advanced state of intoxication,” Carrie Catt reported.

The women and their allies knew they had a one-vote margin of support in the House. Then the speaker, whom they had counted on as a “yes,” changed his mind.

(I love this moment. Women’s suffrage is tied to the railroad track and the train is bearing down fast when suddenly. …)

Suddenly, Harry Burn, the youngest member of the House, a 24-year-old “no” vote from East Tennessee, got up and announced that he had received a letter from his mother telling him to “be a good boy and help Mrs. Catt.”

“I know that a mother’s advice is always the safest for a boy to follow,” Burn said, switching sides.

We celebrate Women’s Suffrage Day on Aug. 26, which is when the amendment officially became part of the Constitution. But I like Aug. 18, which is the day that Harry Burn jumped up in the Tennessee Legislature, waving his mom’s note from home. I told the story once in Atlanta, and a woman in the audience said that when she was visiting her relatives in East Tennessee, she had gone to put a yellow rose on Harry Burn’s grave.

I got a little teary.

“Well, actually,” she added, “it was because I couldn’t find his mother.”

This article has been revised to reflect the following correction:

Correction: August 14, 2010

An earlier version of this article incorrectly stated that the House of Representatives was composed of only men in 1918. Jeannette Rankin, a female representative from Montana, served from 1917 to 1919.

http://www.nytimes.com/2010/08/14/opinion/14collins.html

Dr. Hsiao Lays the Groundwork for his Designs

By Ethan Parke
Vermont for Single Payer Supporter, Montpelier
August 7, 2010

It was an impressive performance on August 5th by Professor William Hsiao, the Harvard health policy economist who has been hired to design three universal health care systems for Vermont. Dr. Hsiao was in Montpelier to give a progress report to the Vermont Health Care Reform Commission.

Using his courteous, often humorous demeanor, and his total command of the subject, Dr. Hsiao deftly fielded skeptical questions and gave every indication that the health care designs he and his team are working on will be comprehensive, evidence-based, and tailored to fit Vermont.

“We’re not doing a design in an ivory tower,” said Dr. Hsiao. “We’re designing something in the real world.” Hsiao said his researchers have been interviewing health care providers, insurance companies, and state officials, to gather background data and to fully understand Vermont’s health care problems and the possible solutions.

Throughout Hsiao’s presentation, what came clear was that in order to control costs and to make health care universal, there must be a rational system. Right now Vermont only has a patchwork of unaffordable insurance based on adverse selection, various government programs, problematic fee-for-service provider compensation, and fragmented financing, Hsiao said.

“No country can control costs unless it has a health care system operating as a whole,” declared Dr. Hsiao. He said Taiwan reduced costs by 8 percent in the first year of its universal health care program—but only because it created a single payer financing mechanism.

State Representative George Till, who is a physician, challenged that assumption. “I agree with your diagnosis, but I don’t agree that the problem must be corrected by a single payer system,” said Till. He asked Hsiao if costs couldn’t be controlled simply by paying all providers the same rate, much like Medicare does.

Dr. Hsiao replied that mandating a uniform payment rate is one aspect of a single payer system, but that in order to control costs you must also unify the payment source as much as possible. Only by taking this extra step can cost shifting be eliminated, and fraud and abuse be kept in check, he said. Hsiao’s implication was that a system that consolidates financing can build in incentives and disincentives to achieve desired results, whereas fragmented financing encourages each provider to find ways for others to pick up costs.

Another commission member, State Senator Kevin Mullen, voiced skepticism on two issues. He said when lawmakers tried to enact health care reform several years ago, IBM objected that it would not want to have employee insurance in Vermont that was different from insurance covering its employees elsewhere. Mullen also said he thought the federal ERISA law would block reform efforts in Vermont. “I worry that we will just be spinning our wheels again,” said Mullen. “I would like to see some real progress next year.”

Hsiao deflected the point about IBM, saying that a company doing business all over the world would be very used to publicly financed health care systems. On the subject of ERISA, Dr. Hsiao joked that “It’s my nightmare.” He said he knows full well that the ERISA law has many interpretations, but added that he is talking to experts at Harvard Law School about the issue.

Two commission members, Con Hogan and State Representative Topper McFaun, said they hoped Hsiao’s work would include as much economic analysis as possible. Unfortunately, said Hsiao, there is only so much his team can accomplish with the funding that has been provided and the short time frame allowed. A key member of Hsiao’s team, renowned MIT economist Jonathan Gruber, will test the three designs using a micro-economic model, Hsiao said. Gruber’s job will be to see how the designs would affect households and employers, but a full macro-economic analysis, looking at the effect of reform on the entire economy, is beyond the scope of Hsiao’s contract. Pressed on this point, Hsiao said he will certainly provide economic analysis, but it will be mostly qualitative and based on economic theory, not on precise numbers.

The three models to be designed by Hsiao’s team are (1) a state run single payer system, (2) a public option within a framework prescribed by the law passed last spring by the legislature, and (3) a consultant-designed plan. This third plan, according to Hsiao, will be designed within political and institutional constraints posed in Vermont. These constraints will be determined, in part, through “stakeholder analysis,” said Hsiao. It was unclear how the third plan might differ from the first, especially given Hsiao’s successful experience with single payer systems worldwide. One possible explanation is that the first design would be more or less a “pure single payer” and the third plan might be a single payer that is modified to fit Vermont realities.

Time will tell which design, if any, the next legislature and the new governor will decide to implement. For the time being, however, single payer supporters should be thrilled that the world’s foremost health system designer is working for Vermont. Dr. Hsiao’s breadth of knowledge, his pragmatic approach, his optimism, and his matter-of-fact endorsement of single payer dazzled his audience last Thursday in Montpelier.

http://vermontforsinglepayer.org/blog/2010/08/dr-hsiao-lays-the-groundwork-for-his-designs/

Is WellPoint's business model viable?

Big and beleaguered: WellPoint’s bad image

By Emily Berry
American Medical News
August 16, 2010
Thus far, WellPoint and insurance trade group America’s Health Insurance Plans have responded to criticism about rate increases with variations on the same theme: Medical costs, driven by physicians and hospitals, are rising so dramatically that insurers cannot avoid raising rates.
The argument doesn’t appear to work if WellPoint and AHIP are trying to elicit sympathy or understanding from the public or policymakers.
As it went on the defensive using studies demonstrating higher medical costs, WellPoint reduced payment for physicians in most of its markets by double-digit percentages for certain procedures, and the cuts were across all specialties, said Susanne Madden, CEO of the consulting firm Verden Group in Nyack, N.Y.
“They’ve done a spectacular job destroying customer loyalty and physician loyalty at the same time, and they’re not making any friends in government,” she said. “They don’t seem to have a grasp on the fact that if they do not have physicians as allies in some way, shape or form, they’re going to have a hard time.”
If it cannot raise rates, WellPoint — and other national insurers — will have to cut costs, experts said. This is where physicians might be affected. WellPoint is likely to cut costs by further reducing payments for hospitals and physicians and restricting networks, experts said.
http://www.ama-assn.org/amednews/2010/08/16/bisa0816.htm

WellPoint’s phenomenal business success has been largely due to its ability to offer competitive premiums by limiting what it has had to pay out in health care benefits. Will WellPoint’s business model continue to be viable?
It has targeted its marketing to the healthy workforce and their young, healthy families, and to the portion of the individual market that can pass underwriting standards. Under the Patient Protection and Affordable Care Act (PPACA) WellPoint will no longer be able to exclude individuals with greater health care needs, neither by favorable selection nor by retroactive rescissions. Without other innovative cost controls, premium increases will be inevitable.
Under PPACA, WellPoint will also be required to provide a standard package of benefits, preventing them from reducing health care spending by cutting benefits. They will also be required to provide plans with tiered actuarial values, prohibiting them from requiring ever greater out-of-pocket cost sharing by the patient. Thus premiums will have to reflect the actual increases in health care costs.
It would be possible for WellPoint to slash reimbursement rates for physicians and hospitals, but that would be a terrible business decision wince it would risk a massive exodus from their provider networks.
It is likely that WellPoint and other insurers will establish more restrictive networks with providers who are willing to accept payment reductions in exchange for greater volume, but that loss of choice would certainly further alienate their plan subscribers, also threatening their market.
The plans may search for other innovations, including some of those in PPACA, but at this time there is little prospect that cost savings could be achieved without creating greater animosity amongst patients and providers.
To comply with PPACA, WellPoint will have to increase premiums and market primarily plans with low actuarial values of 60 or 70 percent, leaving excessive out-of-pocket costs for those with health care needs. The subsidies in PPACA are too small to prevent financial hardship, and there is little political will to expand the federal budget by increasing the subsidies.
The situation can only grow worse with time. The WellPoint model will inevitably end up in the trash heap of failed policies as it is replaced with a single payer national health program – a program that would meet the needs of patients and their health care professionals.

Is WellPoint’s business model viable?

Big and beleaguered: WellPoint’s bad image

By Emily Berry
American Medical News
August 16, 2010

Thus far, WellPoint and insurance trade group America’s Health Insurance Plans have responded to criticism about rate increases with variations on the same theme: Medical costs, driven by physicians and hospitals, are rising so dramatically that insurers cannot avoid raising rates.

The argument doesn’t appear to work if WellPoint and AHIP are trying to elicit sympathy or understanding from the public or policymakers.

As it went on the defensive using studies demonstrating higher medical costs, WellPoint reduced payment for physicians in most of its markets by double-digit percentages for certain procedures, and the cuts were across all specialties, said Susanne Madden, CEO of the consulting firm Verden Group in Nyack, N.Y.

“They’ve done a spectacular job destroying customer loyalty and physician loyalty at the same time, and they’re not making any friends in government,” she said. “They don’t seem to have a grasp on the fact that if they do not have physicians as allies in some way, shape or form, they’re going to have a hard time.”

If it cannot raise rates, WellPoint — and other national insurers — will have to cut costs, experts said. This is where physicians might be affected. WellPoint is likely to cut costs by further reducing payments for hospitals and physicians and restricting networks, experts said.

http://www.ama-assn.org/amednews/2010/08/16/bisa0816.htm

WellPoint’s phenomenal business success has been largely due to its ability to offer competitive premiums by limiting what it has had to pay out in health care benefits. Will WellPoint’s business model continue to be viable?

It has targeted its marketing to the healthy workforce and their young, healthy families, and to the portion of the individual market that can pass underwriting standards. Under the Patient Protection and Affordable Care Act (PPACA) WellPoint will no longer be able to exclude individuals with greater health care needs, neither by favorable selection nor by retroactive rescissions. Without other innovative cost controls, premium increases will be inevitable.

Under PPACA, WellPoint will also be required to provide a standard package of benefits, preventing them from reducing health care spending by cutting benefits. They will also be required to provide plans with tiered actuarial values, prohibiting them from requiring ever greater out-of-pocket cost sharing by the patient. Thus premiums will have to reflect the actual increases in health care costs.

It would be possible for WellPoint to slash reimbursement rates for physicians and hospitals, but that would be a terrible business decision wince it would risk a massive exodus from their provider networks.

It is likely that WellPoint and other insurers will establish more restrictive networks with providers who are willing to accept payment reductions in exchange for greater volume, but that loss of choice would certainly further alienate their plan subscribers, also threatening their market.

The plans may search for other innovations, including some of those in PPACA, but at this time there is little prospect that cost savings could be achieved without creating greater animosity amongst patients and providers.

To comply with PPACA, WellPoint will have to increase premiums and market primarily plans with low actuarial values of 60 or 70 percent, leaving excessive out-of-pocket costs for those with health care needs. The subsidies in PPACA are too small to prevent financial hardship, and there is little political will to expand the federal budget by increasing the subsidies.

The situation can only grow worse with time. The WellPoint model will inevitably end up in the trash heap of failed policies as it is replaced with a single payer national health program – a program that would meet the needs of patients and their health care professionals.