Matthew Holt is a health care consultant, interested observer, and man of strongly held opinions, especially concerning health care and the payment for same. His latest missive is worth a read, regardless of your political leanings or views on socialized v. market-based health care.
Mr. Holt brings up several intriguing points around
— cost v. outcomes;
— the role of government v private payers; and
— who pays for innovation.
If you are pressed for time, print it for plane or train reading – it will get you thinking…
Lost in the character assassination, sophomoric use of labels, political name-calling and sound-bites that passed for an election campaign was any realistic debate about the cost of insuring the uninsured. Bush’s effort was deemed to be too modest, while Kerry accused of bankrupting the system to cover the uninsured.
Now that the dust has settled, it’s likely that there will be little progress in this critical area – health care is not a key issue for most voters (who, after all, have health insurance either from private payers or thru Medicare).
With the politicians absent from the field, now is a good time to return to the issue.
The first question is cost – simply put, how much would it cost?
Fortunately “Health Affairs” published an interesting assessment in late 2003 by two of their editors…
“Using data from surveys of individuals, providers, and government programs, Jack Hadley and John Holahan estimate that uninsured Americans received $35 billion worth of uncompensated health care in 2001. Governments picked up $30.6 billion of the cost, while physicians’ and hospitals’ forgone time, profits, and philanthropy were responsible for between $7.5-$9.8 billion’s worth of care for uninsured Americans.
In a second article, Hadley and Holahan project that it would cost between $33.9 billion and $68.7 billion to cover the uninsured. The lower cost would be under a government program, which would likely pay providers less, while the higher cost assumes the uninsured are enrolled in private-sector insurance plans that pay providers more.”
There you have it. By way of comparison, consider we are spending significantly more than that in Iraq.
There are rumblings that a large number of Republican representatives are pushing to reform the Medicare Prescription Drug Program. Hallelujah.
There are several problems with this ill-conceived and poorly-executed program. They are all related to a core issue – the plan is voluntary and appears to be structured to promote adverse selection; that is, only the people that need drugs will sign up for it. Here’s why.
1. The deductible is very low – $250 annually – and cannot be changed by any health plan.
2. Monthly premiums are estimated to be $35 per senior.
3. There is a late enrollment penalty (that only starts in May of 2006) that is 1% per month. To quote Bob Laszewski of Health Policy and Strategy Associates, you can “wait 30 months until you can make money off the drug plan and it will only cost you $10.50 more per month than if you had enrolled at the beginning.”
What does all this add up to?
Well, seniors will run the numbers. They will calculate what they are paying for drugs today, then add up program’s the monthly premium cost, deductible, their co-pay (25% of the cost of their drugs), and compare the two. Seniors that will “make” money will enroll, seniors that won’t benefit, will stay away.
This is not insurance per se; it is just a terrible business proposition.
Bob’s prediction is not many health plans are going to jump at the opportunity to sell these programs; he’s undoubtedly right.
So, the news that some Congressman have decided they don’t like the program is welcome news. It is somewhat distressing, but wholly unsurprising, that they waited until after the election to have this “ah-hah” moment.
Bill McGuire, MD, chairman and CEO of UnitedHealthGroup, was interviewed by the journal “Health Affairs” recently, including, amongst other topics, UHG’s work in the area of physician practice pattern variation, .
UHG’s approach seems to be to identify centers of excellence for (primarily inpatient) high dollar claims, such as transplants, cancer, orthopedics, etc, and to encourage employers to preferentialy utilize these centers. UHG’s philosophy is to present the information to the employer, and give the employer the option of encouraging the utilization of the preferred centers. The tools available to the employer include benefit design, network customization, and cost sharing.
Not noted in the conversation is any attempt by UHG to provide feedback to non-center of excellence physicians on their practice patterns, the outcomes thereof, and associated costs. Instead, UHG is identifying those providers, down to the surgical team level, that have the best outcomes, and promoting those providers.
Interestingly, McGuire does not promote the use of narrow networks of a few highly-credentialed physicians with best-in-class outcomes.
To quote McGuire;
“I’m not sure that narrow networks get significant savings. Primary care gatekeepers did not lower costs. If people want narrower networks for some reason, we are in a position to facilitate that. But, philosophically, our desire is to bring the overall level of care, by a broad population of care providers, to a higher standard
ACE Insurance’s recent announcement that it is increasing asbestos reserves by almost $300 million may be a case of too little, but perhaps not too late.
Rating agencies have been closely monitoring reserving practices, paying particular attention to the actual amounts set aside as compared to actuarial estimates of future liability. For the layman, this means the companies that determine the financial viability of insurers want to make sure they have set aside enough money to pay for future claims.
This is important stuff – insurance is predicated on the policyholder’s confidence in the insurer’s ability to pay claims. Any concern on the part of present or potential policyholders about this ability is going to hurt the insurance company’s ability to attract new customers.
While one would think the close monitoring of insurance company financials will provide ample warning of impending problems, history shows that when troubles hit insurers, they can collapse seemingly overnight.
In this case, AM Best, one of the leading rating agencies, believes ACE has not set aside enough cash to pay for future asbestos liabilities. Best goes on to say:
“A.M. Best expects that additional charges will need to be taken in the next several years. However, given ACE’s current capital levels and its substantial earnings projections, potential charges taken in subsequent years should be readily absorbed.”
Best did not reduce ACE’s rating. Fitch Ratings (my personal favorite) did cut its rating of an ACE’s subsidiary’s ratings from a B+ to a B- on concerns over future claims and the impact of the charge on overall financials.
Fitch has been very cognizant of the asbestos reserving issue, noting in their latest review of the industry a potential shortfall of $43-$60 billion in reserves for asbestos-related claims at the end of 2003.
While this may seem arcane, esoteric, and generally pretty uninteresting, asbestos reserving practices and results thereof are a key to the viability of many an insurer.
Those who buy insurance should take notice.
The Society for Human Resource Management released a report on the top trends that will affect US businesses in 2005. It comes as no surprise that health care costs led the way, with 57% of respondents naming this issue as the top management concern.
Compare this with a survey conducted last year on opinions of P&C insurance execs, who did not include health care costs in their top eight issues of the year.
Why? Is P&C insurance not affected by health care? No, actually one of the largest cost drivers of medmal, liability, workers comp, private and fleet auto, etc (P&C insurance lines) is health care.
Do P&C carriers have health care costs under control? No, a recent survey indicates medical inflation in one key P&C line is 12% annually, a rate that is significantly higher than overall medical trend.
So why the disconnect?
My guess, and it is only a guess, is a cultural inability to grasp the importance of medical trend. Most P&C insurance execs grew up in the business, viewing claims and the health care part of claims as financial numbers, and thus do not understand health care beyond its’ financial implications. It is viewed as a constant, a black hole, a great unknowable. I’ve heard one exec state “claims are claims, trend is trend”.
With this attitude, no wonder the trend rate is 12%.
The National Governors’ Assn is mounting a surprisingly united front in the battle with the federal government over Medicaid funding . Governors are complaining that the sum of currently proposed and possible federal changes to Medicaid may leave states unable to make up any funding deficit.
Medicaid accounts for 22% of the average state budget, pays for 50% of all long term care and 70% of nursing home costs. Total expenditures for 2004 are estimated at $360 billion, split equally between states and the federal givernment.
Some of the proposed changes look remarkably like the ones implemented in Utah under then-Gov. Mike Leavitt, recently nominated to head HHS. These include (thanks to California HealthLine):
–Allow states to make changes to Medicaid and SCHIP (child health), such as increasing copayments and limiting eligibility, without first obtaining federal waivers;
–Allow local officials to provide different benefits in different parts of a state; and
–Allow states to charge higher fees to higher-income recipients.
Why should the average insurance exec care? Well, this “stuff” usually flows downhill, which likely means cuts in Medicaid reimbursement to providers. Providers will seek to recoup this lost revenue from other sources, particularly those that are soft targets.
Smaller health plans, TPAs, and P&C carriers, take note.
Peter Rousmaniere is both a good friend and a very astute observer of things health care, insurance, political, and just plain interesting in nature. He publishes a daily missive entitled “Three Witnesses”; below is an extract from his 12/30/2004 edition.
I am encouraging Peter to enter the world of the blog – if you agree, please email him at firstname.lastname@example.org.
the passage begins – Washington Post economic strains on American workers worsening
Highly edited down – PFR
“Over the past two decades, companies have moved en masse away from traditional pensions in which employers pay the cost and employees get a set amount after retiring. Employer-based health care coverage has fallen as well, not just for workers in low-wage jobs, but increasingly for those in middle-class jobs. One analysis estimates that there were 5 million fewer jobs providing health insurance in 2004 than there were just three years earlier. Overall, nearly 1 in 5 full-time workers today goes without health insurance; among part-time workers, it’s 1 in 4.
Those who manage to keep their benefits often must pick up their share of the higher cost. Employee contributions for family coverage were 49 percent higher in 2004 than they were in 2001, and contributions for individual coverage were 57 percent higher, according to the Kaiser Family Foundation. ”
I was reading a blog from a practicing generalist, who was making the point that health care costs are increasing due to technology, and that this was benefiting patients. There were no statistics to confirm this (longer life expectancies, better survival rates, improved functionality), but I take his point. There is no question technology is improving many people’s lives.
However, technolgy can be a two-edged sword, especialy for those who get a false negative or positive on a prostate cancer screen, and take/don’t take action based on what is acknowledged to be a very poor test.
As one from the “payer” side, I’d recommend we take the argument on health care costs a step further. Like it or not, employers pay a significant portion of health care costs, both directly (premiums) and indirectly (cost-shifting for uninsured, FICA taxes, income taxes, etc.)
The real issue employers have with health care costs is they have NO sense for their return on the investment. And that is the fault of the medical and managed care communities. Employers carefully assess each investment into plant and equipment, personnel and training, investment options and new products. They calculate RoIs carefully, assess performance constantly, and get as comfortable as possible with an expenditure BEFORE they make the investment.
Think about health care – what do employers get? Happy employees? Rarely – health insurance is a terrible “good” – people only use it when they are ill or injured, it is convoluted and difficult to understand, and they have to pay for part of it too!
Actually, what employers SHOULD be thinking about is the demonstrated ability of a health care provider to “deliver” healthy, fully functional employees and families, thereby enhancing productivity and, therefore RoI. Health insurance is an investment in productivity.
If we can evolve to this way of thinking, much of the present bickering about health care costs will end. Sure, there will be arguments about impact rates, who delivers what benefit, and what evaluation methodology makes the most sense, but that will signal we are talking about the right things.
So, the next time someone complains about charges, costs, or premiums, ask them how that “good” will help them function. They won’t know the answer, but perhaps they’ll start thinking about it.
Here are the top trends in health care as I see them, using the actuarial method of looking back over my shoulder to see what happened, and thereby predicting the future with confidence.
1. More consolidation amongst health insurers.
Many years ago (say, 8 or so) industry pundits were predicting that the health insurance industry would consolidate to a handful of large players, an oligopoly if you will. 2004 has added a lot of credibility to that argument, with Anthem-Wellpoint, Coventry-First Health, and United Healthcare-Oxford three of the more significant. The rationale behind these mergers is classic business school stuff – it is a mature industry, with limited growth opportunities, thereby favoring those companies with market power, economies of scale, and lots of capital/ready access to capital to grow by acquisition.
Expect more of the same in 2005.
2. The return of the hospital
Hospital expenses are the single most powerful driver of overall health care inflation, and they are showing renewed power. Weak hospitals, marginal managers, and bad business concepts have been driven out by the brutal forces of competition and reimbursement, leaving leaner, smarter, more aggressive institutions hardened by years of bargaining with managed care companies.
For now, hospitals hold the upper hand, and managed care firms are having a much tougher time at the negotiating table.
Expect this to remain the case throughout 2005.
3. Cuts in Medicaid and Medicare
Mr. Bush’s desire to reduce federal expenditures over the long term will result in significant changes in these behemoth programs. Health care costs are a huge portion of the federal budget, and present an attractive target to those focused on cutting deficits. Some of this is already apparent in the (latest) strident campaign to cut out “waste and abuse”.
There will very likely be tough cuts in hospital and physician reimbursement over the next two years, and perhaps a drastic overhaul of Medicaid in the form of block grants to states rather than the present “defined benefits” program model. When CMS shudders, the rest of the health care community quakes. These providers will look to recoup their lost revenue from somewhere…
Expect a very heated battle, with Bush et al eventually pushing through a drastic overhaul of these two “Great Society” programs.