On Jan. 1, UPMC will achieve its long-sought divorce from Highmark. The separation will undoubtedly disrupt care, add untold stress and potentially harm thousands. UPMC, in refusing even to negotiate a renewed contract, has plainly driven the breakup.
UPMC’s grounds for divorcing Highmark are tenuous. In testimony to the Legislature, UPMC complained that Highmark threatens to injure UPMC by “steering” patients to the “now-struggling” Allegheny Health Network, which Highmark has supported to serve as competitive foil to UPMC.
UPMC further explained, “Western Pennsylvania simply has too many hospital beds, and any gain in admissions at one hospital must come at the expense of other hospitals.”
In brief, UPMC believes competition against Highmark is good, but competition against UPMC is bad. UPMC touts creation of the UPMC Health Plan as “a competitive thorn in Highmark’s side,” but derides its own competitors as malevolent meddlers. As once explained by its CEO, UPMC’s goal is to create a “benevolent monopoly.” Unfortunately, monopolies are rarely benevolent, and there is nothing suggesting that UPMC would forgo (untaxed) profits for the public good.
Category: Private Health Insurance
Adventures in ‘Prior Authorization’ – NYTimes.com
DEAR Doctor,” the letter from the insurance company began. “We are writing to inform you that a prior authorization is required for the medication you prescribed.”
That’s usually where I stop reading. Thousands of these letters arrive daily in doctors’ offices across the country. They are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, you need to provide a compelling clinical reason.
In theory, this is a reasonable way to control costs by making it harder to prescribe costlier medications. In practice, it is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles.
One study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. Other studies have suggested that prior authorizations could cost individual practices tens of thousands of dollars a year.
Insurers Once on the Fence Plan to Join Health Exchanges in ’15 – NYTimes.com
In a sign of the growing potential under the federal health care law, several insurers that have been sitting on the sidelines say they will sell policies on the new exchanges in the coming year, and others plan to expand their offerings to more states.
“Insurers continue to see this as a good business opportunity,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. “They see it as an attractive market, with enrollment expected to ramp up in the second year.” Eight million people have signed up for coverage in 2014, and estimates put next year’s enrollment around 13 million.
In New Hampshire, for example, where Anthem Blue Cross is the only insurer offering individual coverage on the state exchange, two other plans, both from Massachusetts, say they intend to offer policies next year. Harvard Pilgrim Health Care, a nonprofit insurer with 1.2 million members, said it expected to participate in the exchanges in both New Hampshire and Maine for the first time and to add Connecticut to the mix in 2016.
Insurers Once on the Fence Plan to Join Health Exchanges in ’15 – NYTimes.com
Opinion: Cancer survivor: Obamacare got me covered – CNN.com
In January, for the first time since my diagnosis 36 years ago, I will have an individual health plan that offers quality coverage for me and my family. I will save $628 every month on premiums. Best of all — I wasn’t even asked if I’ve ever had cancer.
Opinion: Cancer survivor: Obamacare got me covered – CNN.com
‘Premium Shock’ and ‘Premium Joy’ Under the Affordable Care Act – NYTimes.com Uwe Reinhardt
Community Rating Under the Affordable Care Act
Under the law, an individual health plan selling policies in the small-group and nongroup market — whether it sells policies through the state’s exchange or not — will be free to set its own premium for a given policy. But within a given age group, it must apply the same premium to all comers, regardless of their health and their gender. Furthermore, the health plan cannot reject any applicant willing to pay that premium, a provision called “guaranteed issue,” or cancel existing policies.
In other words, the Xi based on the individual’s health status in the equation above will be replaced by the average expected health spending per insured, with the average calculated over the insurer’s entire anticipated risk pool of insured members of a given age. To calculate the average, the insurer must consider as one single risk pool all enrollees in all health plans offered by the insurer, whether or not they are offered on the exchange.
This form of premium setting is known as “community rating.” Because it forces healthier individuals to subsidize sicker individuals through the community-rated premiums, it has been much debated.
Community rating invites “cherry-picking” by insurers — i.e., attempts to attract mainly low-risk applicants. To limit the profit potential from cherry-picking, there will be post-enrollment risk adjustments through which funds are transferred from insurers ending up with relatively healthier risk pools to those ending up with relatively higher risk pools.
The community rating under the law is not the pure version found in the social insurance systems of Europe (e.g., Switzerland, the Netherlands and Germany) or Asia, where even age is not considered in setting premiums. Rather, the American version is called adjusted community rating, because it does allow insurers to adjust the community-rated premium for the age of the applicant.
Age-adjusting is done by multiplying the community-rated premium for the youngest members in the expected risk pool by a standard, multiplicative age ratio to be used by all insurers. Thus the quoted premium can increase step by step with age, but only up to a multiplicative factor of 3. At a given age, smokers can be charged up to 1.5 times the regular premium.
The change from what was in place before the Affordable Care Act to post-law arrangements in the nongroup market can be illustrated graphically. In the chart below, we assume initially that all members of a given population are covered by either medically underwritten or community-rated health insurance, with a given package of covered health benefits. The white line represents the premium individuals would have to pay under medical underwriting. The dashed segment of that line is meant to show the actuarial cost and the premium range in which insurers in the real world would reject applicants outright. The green line shows the community-rated premium for this same population. We assume here that age is either not factored into the premium or the population in question is all of the same age, which is why the green line is horizontal.
Premium Shock
As the chart illustrates, a switch from medically underwritten premiums to community-rated ones raises the premiums for the relatively healthier members of the insurer’s risk pool. Many of them will suffer what has come to be called premium shock.
Younger and healthier members of the pool should realize that, in effect, they are buying a call option that allows them to buy coverage at a premium far below the high actuarial cost of covering them when they are sicker. The price charged the healthy for this call option is the difference between the premium they must pay and the current lower actuarial cost of covering them.
Furthermore, for Americans in households with incomes below 400 percent of the federal poverty line, the green and red lines exaggerate the impact of the law on their spending. These Americans will be granted often quite generous, income-dependent federal subsidies toward the premiums they face on the exchanges and their out-of-pocket costs for health care. This makes it well-nigh impossible to make general statements, based on averages, about the net after-subsidy impact of the law.
‘Premium Shock’ and ‘Premium Joy’ Under the Affordable Care Act – NYTimes.com
NEJM — Netherlands and Managed Competition
The myth that competition has been key to cost containment in the Netherlands has obscured a crucial reality. Health care systems in Europe, Canada, Japan, and beyond, all of which spend much less than the United States on medical services, rely on regulation of prices, coordinated payment, budgets, and in some cases limits on selected expensive medical technologies, to contain health care spending.5 Systemwide regulation of spending, rather than competition among insurers, is the key to controlling health care costs. The Netherlands, after all, spent much less on medical care than the United States with virtually universal insurance coverage long before it began experimenting with managed competition in 2006.
The Dutch experience provides a cautionary tale about the place of private insurance competition in health care reform. The Dutch reforms have fallen far short of expectations — a reminder that policy intentions should not be confused with outcomes and that managed competition is hardly a panacea. The idea that the Dutch reforms provide a successful model for U.S. Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in U.S. health care reform debates.5 Before we learn from other countries’ experiences with medical care, we first need to learn about them.
In Conservative Arizona, Government-Run Health Care That Works – Kaiser Health News
APACHE JUNCTION, Ariz. – In a low-slung building in the vast desert expanse east of Phoenix, a small school of tropical fish peer out, improbably, from a circular tank into the waiting lounge of the Apache Junction Health Center. The hallways of the nursing home are still. Only half of the rooms are filled, and the men and women who live here seem surely in life’s final season. “These are folks that have chronic cognitive and physical disabilities that are not going to improve,” said George Jacobson, administrator of the nursing home.
That this nursing home is sparsely filled with residents too disabled in mind or body to return home is a stunning achievement for Arizona’s public health insurance agency. A decade ago, 60 percent of Arizonans covered by Medicare and Medicaid, and deemed sick, frail or disabled enough to live in a nursing home, resided in a skilled nursing facility. Today, only 27 percent of them do, and the rest – nearly three out of four– live in assisted living facilities or at home with the help of nurses, attendants and case managers provided by government-paid health plans.
As Congress debates an ambitious and far-reaching effort by the Obama administration to streamline medical care and rein in spending for the nation’s sickest and most expensive patients, Arizona – with its finger-wagging Republican governor and Tea Party enthusiasts – is occupying an unusual place in the national landscape: as a model for how a generously-funded, tightly regulated government program can aid vulnerable, low-income patients.
In Conservative Arizona, Government-Run Health Care That Works – Kaiser Health News
The Bomb Buried In Obamacare Explodes Today-Hallelujah! – Forbes
The Bomb Buried In Obamacare Explodes Today-Hallelujah! – Forbes:
This is the true ‘bomb’ contained in Obamacare and the one item that will have more impact on the future of how medical care is paid for in this country than anything we’ve seen in quite some time. Indeed, it is this aspect of the law that represents the true ‘death panel’ found in Obamacare—but not one that is going to lead to the death of American consumers. Rather, the medical loss ratio will, ultimately, lead to the death of large parts of the private, for-profit health insurance industry.
Why? Because there is absolutely no way for-profit health insurers are going to be able to learn how to get by and still make a profit while being forced to spend at least 80 percent of their receipts providing their customers with the coverage for which they paid. If they could, we likely would never have seen the extraordinary efforts made by these companies to avoid paying benefits to their customers at the very moment they need it the most.
Today, that bomb goes off.
Today, the Department of Health & Human Services issues the rules of what insurer expenditures will—and will not—qualify as a medical expense for purposes of meeting the requirement.
As it turns out, HHS isn’t screwing around. They actually mean to see to it that the insurance companies spend what they should taking care of their customers.
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AHIP’s Commissioned Report
In case you’re looking for good analysis of the AHIP shot across the bow…
http://www.newamerica.net/blog/new-health-dialogue/2009/health-reform-ahip-got-what-it-paid-15314
http://www.newamerica.net/blog/new-health-dialogue/2009/health-reform-gloves-are-15299
George Lakoff: The PolicySpeak Disaster for Health Care
George Lakoff: The PolicySpeak Disaster for Health Care:
The narrative is simple:
Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.
Language
As for language, the term ‘public option’ is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that’s what it really is.
The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It’s got conservative veterans at Town Hall meeting shouting things like, ‘I fought for this country in Vietnam, and I’m fight for it here.’ Progressives should be stressing the patriotic nature of having our nation guaranteeing care for our people.
A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. 50 million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can’t wait any longer. It’s an emergency. We have to act now to end the suffering and death.
Doctor-Patient care. This is what the public plan is really about. Call it that. You have said it, buried in PolicySpeak. Use the slogan. Repeat it. Have every spokesperson repeat it.
Coverage is not care. You think you’re insured. You very well may not be, because insurance companies make money by denying you care.
Deny you care… Use the words. That’s what all the paperwork and administrative costs of insurance companies are about – denying you care if they can.
Insurance company profit-based plans. The bottom line is the bottom line for insurance companies. Say it.Private Taxation. Insurance companies have the power to tax and they tax the public mightily. When 20% – 30% of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96% of voters that
have health care. But the tax does not go to benefit those who are taxed; it
benefits managers and investors. And the people taxed have no representation.
Insurance company health care is a huge example of taxation without representation. And you can’t vote out the people who have taxed you. The American Plan offers an alternative to private taxation.
Is it time for progressive tea parties at insurance company offices?Doctors care; insurance companies don’t. A public plan aims to put care back into the hands of doctors.
Insurance company bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.Insurance companies ration care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does
you primary care physician have to rush you through? Have your out-of-pocket
costs gone up? Ask these questions. You know the answers. It’s because insurance
companies have been rationing care. Say it.
Insurance companies are inefficient and wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.
Insurance companies govern your lives. They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.The health care failure is an insurance company failure. Why keep a failing system? Augment it. Give an alternative.