Making it Simpler: Reinventing Individual Health Insurance

KISS, as a business imperative, is cited so often it’s passed beyond cliché to become background noise. Keep It Simple Stupid, however, is more of an illusive ideal than a comfortable accomplishment for most businesses. The individual health insurance industry is no exception – yet it needs to be.

 

Consumers buying medical coverage for themselves and their families lack the support network larger enterprises have. They (hopefully) are working with an independent insurance agent who understands their needs and knows the way through the maze of getting coverage, fixing billing problems or getting claims paid. But there’s no human resources department in the living room or colleagues to call upon for help in the kitchen. Worse, for those without an agent, there’s often no one to call for help than the carrier itself.

 

This isn’t necessarily a bad thing. Many people working in carriers’ membership service departments are quite good – once you get past the dreaded phone system. (I just dealt with a customer service rep at the health plan for my small business who solved the problem in one phone call – and was nice about it to boot).

 

The thing is, however, if you need to call for help, then something isn’t working right. Getting health insurance shouldn’t be complicated. Neither should understanding bills or explanations of benefits (EOBs). And doctors and hospitals shouldn’t have to devote so much resources and time into their interactions with health plans.

 

If Google can make searching the web clean and simple, if Apple can make a cell phone/music player/ PDA elegant and straightforward, if Visa and Mastercard can present payment histories in a relatively easy to understand manner, if Southwest can make booking a flight a breeze, then certainly health plans could simplify their processes.

 

A place to start would be with the products themselves. Each carrier describes their benefits in their own terms. Surely there’s a best practice for this kind of thing, but every carrier has its own unique and often idiosyncratic method. The result: agents (and their clients) devote hours to creating their own apples-to-apples comparisons.

 

There are the conspiracy theorists out there who believe this is done to make it more difficult for consumers to understand what they’re buying. I believe their wrong: why assume bad intent when indifference or incompetence explains the situation? When it comes to presenting benefits I think it’s more a case of an inward orientation with a dash of pride of authorship thrown in.

 

Or take provider directories. Many have moved online, but again, there’s a best practice out there that would make finding your doctor even easier. Or claim forms. Every doctor I see (and at my age it’s more than one, now) complains about the paper work. There have been efforts to move claim submittals online, but the problems with the process are more than technical. There’s also a need to simply make the process simpler. There’s a place for uniqueness. Commodity material is rarely that place.

 

Instead, the focus needs to be on something somewhat foreign to most health plans: design. Design has become a hot business concept. Magazines like Fast Company, Inc., Fortune fawn over the concept and those who excel at it. Products like iPods and half the house wares at Target are held up as icons of a new business paradigm.

 

Yet design shouldn’t be the sole purview of gadget manufacturers or fashion designers. Processes can be well designed, too; so can forms. But good design will only come to the work flows and materials of health plans if it’s a priority of their leadership. And that takes some courage. It’s not easy to make being easy a corporate priority, especially when your industry is under fire.

 

Yet those attacks can be seen as a motivator for simplification, too. For example, individual health plans are going to have change the way they underwrite applications. Their ability to discover fraudulent applications is going to be extremely limited once lawmakers get done reforming the rescission process. With no back-up, the importance of underwriting at the front-end becomes even more critical than it already is.

 

This is a great opportunity to make enrollment applications simpler. Again, there are those who claim the applications are complicated to enable carriers to play “gotcha” with their members who later incur claims. They have no facts to back this up, but that hardly matters, especially when these critics get a lot of attention just for making the claim. Which means carriers are going to have to deal with this charge for quite awhile – or until something changes.

 

(What’s more likely to blame for complex applications is the same dynamic that haunts anything created by committee. When lawyers, underwriters, actuaries, and business managers sit down to create a form – especially one that needs to meet regulatory standards – that form is going to be bloated, complicated and annoying. No ulterior motive is required.)

 

Instead of spending time repeatedly repudiating the charge, however, health plans would be better served to move beyond it. The fact is, applications are more cumbersome and complicated than they should be. Carriers should work with their Departments of Insurance and an outside design consultant to come up with standardized and, even more importantly, simplified underwriting forms. The forms should focus on making it as easy as possible for consumers to provide enough information for the carriers to make their underwriting decisions.

 

And that should be the explicit goal: easy sufficiency. This, in turn, means using simple language in a clear, concise manner. It means laying out the questions in a manner that flows and avoids asking for the same information repeatedly. It’s a lot easier to describe than do (I know, I tried once), but if made a priority, it’s doable.

 

When lawmakers, prosecutors and others are lobbing grenades your way it might be counter-intuitive to use the situation to focus on design. In reality, simplifying the touch points where consumers, agents and medical providers interact with the carrier is an extremely visible way of demonstrating a commitment to change. As important, it’s a vehicle for getting in front of the change that is inevitable.

Executing the Basics: Reinventing Individual Health Insurance

The best strategy in the game, the most inspiring vision in the industry means nothing without execution. And if an organization isn’t executing the basic components of the business, implementing something fancy — culture change, a new business model — isn’t going to get very far.

Executing the basics is the least exciting critical component of any successful business. By definition, a successful business has proven itself. It’s an ongoing concern. Leaders like to lead and that usually involves moving in new, more exciting directions. Over time, attention to the nuts and bolts can wane. The basics become a source for savings. The attention moves from serving the customer to an internal focus on efficiency. After all, resources need to be freed up to fund those new initiatives.

In the context of individual health insurance, the basics include processing applications, issuing bills, paying claims, contracting with doctors, appointing agents, and answering the phone. Most carriers do an adequate job on these items most of the time. All carriers do a lousy job on some of these at some time. Those osciallations in performance are normal and to be expected. What’s unacceptable is that “adequate” is, well, acceptable. Carriers will talk about delivering first class customer service, being partners with their providers and producers, but few, if any, consistently succeed.

The problem, I believe, is two-fold: an inability to measure the return on investment of better service; and an unwillingness for competitors to cooperate.

Providing services, whether it’s underwriting applications, answering questions from insureds and their physicians, or paying commissions, costs money. These dollars can be measured, tallied and monitored. Given the need to keep coverage affordable, the appropriate goal for carriers is to provide these services as efficiently (meaning at the lowest cost) as possible.

These services also have benefits in the form of customer satisfaction, increased efficiencies at the partner level (less time spent in doctors offices tracking down an answer freeing up more time to work with patients), and a negative public image. The problem is that dollars are a lot easier to track than satisfaction or efficiency in someone else’s office. So when carriers do a cost benefit analysis on a new IVR system (IVRs are those automated “press 1″ or “say ‘billing’” phone routing systems) they can measure the savings in personnel costs, but they lack the tools to measure the increased frustration members feel when unable to make the artificial (un)intelligence get them to the right place.

Health plans aren’t the only industry with frustrating phone systems. Sprint, AT&T, Time Warner, DirecTV and Verizon are a few others with IVRs deserving of a shout-out — or shut down, depending on your point of view. But cable and phone utilities are not the standard to which carriers should hold themselves. Nor should the standard be Nordstrom or Starbucks. It should be what consumers define as good customer service, doctors define as good physician service, and producers define as good agent service.

Carriers need to examine their basic operations from the consumer point of view. They need to define customer expectations and then think about ways to deliver those services in a cost-effective way that meets those expectations.

This means shifting the focus from an internal point-of-view to one that looks at operations through the eyes of the consumer (or physician or agent). This isn’t hard: every officer in every health plan should be required to call their customer service departments on a monthly basis. They should get a monthly bill and call in with a question. They should receive an Explanation of Benefits (EOBs) and be asked how much and to whom they would cut a check if it was for real. They should call in to the pre-authorization phone line and follow-up on an application. In other words, they should walk in their customer shoes at least monthly. Then, on a quarterly basis, their staff meetings should focus on what they experienced.

There’s other techniques that work. For example, executives and managers should be required to plug in and listen to phone calls between their service reps and customers. Not occasionally, but in a regular, disciplined way.

Carriers also need to find ways to quantify something more than dollars. Perhaps bonuses should be impacted by customer satisfaction survey results or even public surveys. Or, perhaps they should ask someone. Fortunately for carriers, there’s too many economists in the world with too little to do. Certainly some of them have come up with mathematical formulas for measuring intangibles. Give them a call — they’re hungry for someone to talk to. Make your CFOs sit down with them and come up with a formula that works.

And then share the results. Which is the other part of the challenge. Most businesses tend to think that everything they do must be confidential and proprietary. The market is a jungle and every advantage needs to be exploited to survive. In this mindset, advantages are to be hoarded, not diluted by sharing.

The problem is that most customers don’t really care about a lot of these proprietary advantages. An example from a book I read, but now forget the title, describes the foolishness of the auto industry when lawmakers required them to incorporate catalytic converters into their cars. Each auto maker spent many millions of dollars to invent and implement their own design. Yet who has ever purchased a car because of its catalytic converter? The industry could have redirected most of those dollars to features that matter if they had come together and designed a standard converter they all could have used.

This concept of standardizing and sharing resources is much more acceptable in the software world where open source systems like Linux and MySQL are widely used. It’s foreign to most companies, including carriers. 

Yet the opportunity to standardize and share resources is huge in the industry. Applications for coverage, claim forms, EOBs, bills, commission statements aren’t competitive advantages — their Babel-like diversity is merely a source of frustration for users. Better yet, by standardizing them, entrepreneurs could develop tools to increase efficiency for the carriers and convenience for consumers.

Consider: most carriers currently accept online applications from large producers like eHealthinsurance. Yet, as large as eHealthinsurance’s production is, it represents a small percentage of carriers’ overall sales. Why create mechanisms that benefit just a few agencies? Instead, carriers should agree on standards for quoting and case submission systems that works for all health plans in all states. These standards should be freely distributed as open-source software. eHealthinsurance may compete in the market based on its quoting system, but carriers don’t. By creating a publishing low- or no-cost software carriers can more easily implement customer friendly services like automated underwriting, immediate issuance of membership cards and the like.

Standardization doesn’t mean customization isn’t allowed. There are several flavors of Linux commercially available. Similarly, entrepreneurs could take the open-source quoting/submittal software and package them, adding new interfaces and functionality. So long as carriers standardize around the basics, however, they should all save money, increase efficiency and improve customer satisfaction with the industry as a whole. They could then use the freed-up funds to better compete on what does matter to consumers: benefit design, cost of coverage, and the like.

Would this kind of cooperation be legal? It depends on how it’s approached. The standards negotiations can be outsourced to an independent third party. Or they can be convened under the auspices of regulators. In California, Insurance Commissioner Steve Poizner has done something similar and has expressed an interest in helping carriers appropriately address common challenges. So yes, it can be done legally.

Attending to the basics is not exciting, but it can be impactful. Perhaps more importantly, invigorating innovations will fail unless they’re built on a strong foundation. So if the individual health insurance industry is going to reinvent itself, the nuts-and-bolts of the business is where it has to begin.

 

Reinventing Individual Coverage: Defining the Approach

In my previous post I suggested the current political environment provides more than sufficient inspiration for individual health insurance industry to reinvent itself. One of the challenges to actually implementing change is figuring out how to approach the problem. It’s often too easy to get caught up in the details without remembering the goal.

And the goal here is to deliver value to consumers who purchase their own health insurance coverage. This may seem obvious, but in too many cases, industry insiders and reformers at the barricades alike get so caught up in rules and regulations, processes and work flows, structure and platforms that they lose site of this simple truth: at the end of the day we either provide value to consumers … or else.

And it’s a truth that is agnostic as to whether the “we” is a private enterprise or a government agency. We either deliver or we go away.

So instead of structuring the gratuitous advice I intend to offer over the next several posts on specific items (dealing with rescissions, simplifying the application, etc.) I’m going to focus on a few general themes. Specifics may crop up as examples or to help amplify the themes, but it’s the overarching themes that provide a framework for change.

As of now, I’m inclined toward four major themes:

1. Executing the Basics
2. Making it Simpler
3. Sharing Technology
4. Earning Trust

Executing the Basics is all about the nuts-and-bolts of being a health insurer. Processing applications, issuing bills, paying claims, contracting with doctors, appointing agents, and answering the phone.

Making it Simpler recognizes that individuals are not businesses, even when they have the assistance and counsel of a qualified agent. Health insurance coverage is complicated enough. The process of getting and using it, however, shouldn’t be as complicated as it is. Nor should finding the plan that best fits a family’s need. Nor filing a claim. Nor … well, you get the idea.

Sharing Technology stresses that a carriers’ sales and member service technology shouldn’t drive consumers’ buying decision. A health plan’s benefit design, pricing, access to providers and the carriers’ customer service offerings should.  The industry could save millions of dollars by adopting standards that any and all technology providers can use for everything from accepting online applications, issuing online membership cards, processing claims, creating provider directories, etc.

Earning Trust may be the most important theme. After more than a year of every major office holder in the country calling the system broken, after endless legislative hearings, headlines and press conferences attacking the industry, consumer confidence in the industry is lower than its ever been. Worse, this only seems to inspire supposed industry insiders to pile on. The fact is there are problems in any enterprise, public or private. What’s needed is facing them honestly, not to score points.  Most of all, earning trust means raising the standards of behavior and meeting them.

These themes overlap with one another. What works in one area might well impact another. But they provide a general framework for discussing ways to reinvent individual health insurance. At least they are the themes I’ll be addressing over the next several days. Do you have others you think need to be considered? Are these off-target? Please let me know your thoughts by posting a comment. 

Reinventing the Individual Health Insurance Market

The health insurance industry has been under attack for years. There are those who would like to do away with it completely. While those voices have grown louder in recent years their political success has been limited at best. For evidence, just look at the campaign for the Democratic presidential nomination: no major candidate called for a government-run, single-payer system. The two remaining contenders have both explicitly taken such an approach off the table.

Yet there is one aspect of the industry that is under intense attack: the individual market. Again, this isn’t new. In the past, however, most of the attacks have been unfocused or ill-informed. Critics tended to ignore unique aspects of the coverage targeted at individuals and families buying insurance outside of work: it’s a voluntary decision. To maintain affordable premiums carriers must weed out potential buyers who are certain to incur substantial claims.

For example, carriers will often reject an applicant who is a regular user of a particular prescription drug. This strikes many as wrong, if not immoral. Just because someone needs a certain medication is no reason to deny them insurance.

Yet, when the monthly prescription costs exceeds the monthly premium, what else can the carrier do? Insurance is about spreading risk. In a voluntary market where people can choose when to purchase coverage, it means they need to buy insurance before their known risks exceeds the premium. Otherwise, they are simply asking other consumers to subsidize them. This dynamic, known as adverse selection, is at the root of much of the problems facing the individual market.

It’s not the only cause, however. Carriers exacerbated the problem by mishandling their approach to managing adverse selection. The most obvious mistakes involved how rescissions were handled. Even the industry’s most ardent foes admit carriers need to protect themselves from fraud. If an applicant knowingly and intentionally lies about material information on an application for coverage, the carrier should have the right to revoke the coverage.

It’s identifying when the misstatements are knowingly and intentionally that creates a gray area. Carriers chose to be aggressive in applying their right to rescind coverage. Now they’re paying a huge cost for this posture in the form of large fines, law suits and horrendous publicity.

The rescission issue is the hammer being used by lawmakers, regulators and pundits interested in reshaping the individual health insurance market. That their proposals would be more likely to do more harm (in the form of higher prices and less consumer choice) than good seems almost beside the point. They want change. They want it now.

While their changes are often off target their goal may not be. Perhaps the attack on the this market segment is what’s needed to prod the industry to reform itself. Perhaps it’s the motivation needed to reinvent the individual health insurance market, to make it stronger, more valuable and more respected than in the past.

I’ll be writing about the opportunities for reinvigorating the individual market over the next several days. I hope you’ll share your ideas, too. Please post your thoughts on ways to reinvent individual health insurance products, the way they’re sold, administered and used. By the end of this dialogue we’ll at the very least have built a list of alternatives to some of the misguided proposals currently being considered in Sacramento, Washington D.C. and elsewhere. At best, someone who can actually implement the changes may be inspired by your thoughts and meaningful change will follow.

Stay tuned.  

State Budget Cutting Holes in Health Care Safety Net

Say what you will about Governor Arnold Schwarzenegger’s failed health care reform plan, it’s goal was noble. If it had worked as planed (which is highly unlikely) it would have not only brought millions of Californians into the health care coverage system, but would have strengthened the state’s medical safety net. Instead, the health care plan failed, the California budget is in tatters and that safety net is in grave danger.

Community health clinics and community health centers play a critical role in assuring that uninsured Californians obtain the health care treatment they need. As is often noted in health care reform debates, no one goes without care. The “safety net” is there to assure treatment is available to everyone. Community health care centers, for example, provide a medical home to 3.6 million uninsured Californians, according to Jason Vega of the Community Clinic Consortiumof Contra Costa and Solano counties.

What’s often overlooked, however, is how fragile that safety net really is. Part of the reason is demand. With millions of uninsured and underinsured Californians, community clinics and the like have no shortfall of clients. The quality of the care provided belies the cost of the care to those patients, who usually pay what they can — if they can at all.

The vast bulk of the funds for community clinics comes from donors and, even more importantly, from government health care programs. And that’s where the danger arises.

Under the Schwarzenegger health care plan, Medi-Cal reimbursement rates (what the state pays doctors, hospitals and clinics) was to increase. There’s certainly room for an increase: California’s reimbursement rates are among the lowest in the country.

But the health care plan failed. Part of the reason was the state’s dire fiscal condition. Even with draconian cuts recently enacted by lawmakers in Sacramento, the state needs to close a multi-billion budget gap. One way they’re likely to do that is to reduce Medi-Cal reimbursement. That, in turn, means fewer doctors will take Medi-Cal patients and, of those that do, many will see fewer of them. And that means more patients turning to community clinics.

The safety net is a critical component of today’s health care system. For those who oppose a government takeover of medical care, it is an element of the system that needs to be strengthened and protected. Yet that’s not happening now. And if the safety net disappears, the government will rush in to fill the vacumn, at great expense and to the detriment of consumer choice.

All this underscores the need for comprehensive health care reform that attacks skyrocketing medical costs while bringing more residents into the health care coverage system. I’m skeptical about whether states are in a position to accomplish this, but the federal government certainly can. As a new administration approaches this task in 2009, they need to make sure the health and vitality of the nation’s community clinics and its partners in the safety net are top of mind.

State Reform Issues More Incremental than Comprehensive

My personal belief is that comprehensive health care reform is more likely to come from federal action than anything the states do over the next couple of years. That’s certainly true in California where lawmakers are now focused on attacking specific problems rather than fixing the entire system. But the obstacles to state efforts are more than exhaustion, as I’ve written previously, states have limited resources and even more limited levers to exact change on systems as complex as the nation’s health care system.

Yet incremental reforms can make a difference, too, and several states have enacted or are considering interesting approaches. Aetna publishes a “Health Reform Weekly” it distributes to agents (among others) and their March 24th issue provided a roundup of state reform activity. I’ve taken the liberty of  reproducing much of it below. As you’ll see, with the exception of New Jersey — and to a lesser extent, Florida — these are hardly comprehensive efforts:

CONNECTICUT: Many of the health care measures approved by the Insurance Committee last week are focused on the high cost of health care. One of the committee-approved proposals would establish a wellness tax credit for small businesses; another would allow more flexibility to offer lower-cost health plans. Another proposal would allow municipalities to collaborate together to purchase health insurance. The House put forth the Healthy Steps Program, which permits the sale of reduced-mandate products, requires a cost-benefit analysis of mandates and establishes business tax credits for providing employees with health insurance. The Insurance Committee did not act on the “pay or play” health care tax bill, nor did it act on legislation that would dictate the provisions and terms included in the contracts between health insurers and physicians. Disposing of these proposals early in the session provides a boost to the business climate in Connecticut.

FLORIDA: Governor Charlie Crist’s “Cover Florida” plan for the uninsured passed out of its first committee last week and continues to move forward.Aetna has worked with the Governor’s office for several months on this proposal and has been successful in seeing a number of suggestions incorporated into this version. Health plan participation in the plan would be voluntary. Though Cover Florida still contains guaranteed issue language affecting participating plans, the plan would allow pre-existing condition exclusions as well as benefit limits.

GEORGIA: Action on the Georgia Medical Association’s prompt-pay proposal was postponed last week, but it may be acted on in committee this week.While it still contains language applying the prompt-pay requirements to self-insured plans, Aetna has been able to help reduce the bill’s impact by assuring health plans are not assessed penalties regarding prompt payment of claims unless they are below a 95 percent compliance standard. Also, the interest penalty has been reduced from 18 percent to 12 percent.

INDIANA: The Legislature adjourned the 2008 session on March 14. In recent weeks, an Assignment of Benefits bill died in the Senate.However, a “Silent PPO” bill made it through the process. After much negotiation, the industry supported the bill, which requires greater disclosure of information regarding the rental of PPO networks. The provider community attempted to include much more far-reaching, costly, and unnecessary items to the bill, but those were ultimately defeated.

MASSACHUSETTS: Commonwealth Choice health insurance premiums projected for this summer will average 5 percent more than last July’s rates.A state panel last week approved a contract to pay insurers about 10 percent more for each person enrolled in the subsidized insurance program starting July 1, making the lowest premiums in Commonwealth Care $39 a month to $116 a month. Insurers had asked for an increase of about 15 percent but agreed to less after weeks of negotiations. Under the contract, the state also would assume more of the financial risk if the enrollees were to use more medical care than expected. The Connector’s Executive Director John Kingsdale recently reported that more than 300,000 Massachusetts residents have enrolled who were previously uninsured. This large number suggests that the state’s official estimate of the number of uninsured (372,000) was low, so the cost of solving this bigger problem is going to be significantly more than originally thought (an estimated $869 million in FY ‘09 instead of $725 million).

NEW JERSEY: Senators Joseph Vitale and Robert Singer and Assemblymen Neil Cohen and Lou Greenwald joined David Knowlton, President of the New Jersey Health Care Quality Institute, last week in announcing a comprehensive health care reform initiative - the Vitale Plan - with the goal of achieving universal coverage in New Jersey.Phase One would feature a Kids First mandate requiring coverage of all children under 18; expansion of New Jersey Family Care to 200 percent of the federal poverty level; and small group and individual market reforms, including prior approval by the Department of Banking and Insurance for premium increases of more than 15 percent, an increase in MLR from 75 percent to 80 percent, and a requirement that insurers selling small group market products also sell in the individual market. Phase 2 would feature an individual coverage requirement, and establishment of a state-operated health insurance plan administered (ASO) by two insurance carriers. Projected costs for the first year total $28.8 million (of which $20.5 is for the children’s component), and funding is purportedly available at present in the form of surpluses totaling $180 million in the state’s Family Care and Medicaid Programs.

SOUTH DAKOTA: The Legislature adjourned its 2008 session on March 17.Recent legislative action includes passage of a transparency bill, which requires licensed hospitals to report charges for any procedure for which the hospital had at least 10 cases. The data will be reported to the South Dakota Association of Healthcare Organizations, which is required to develop a web-based system for making the information available to the public via a link from the Department of Health’s website. In addition, the law requires the dissemination of information about physicians’ charges for certain outpatient procedures.

TENNESSEE: The Tennessee Medical Association this week announced it now officially supports the “Silent PPO” legislation originally introduced by some individual providers.The bill closely follows the AMA model on this issue and contains significant restrictions on insurers’ ability to operate rental networks. Aetna is working with the industry to defeat this legislation.

State lawmakers are not going to ignore health care issues. Nor should they. But when it comes to substantial changes to the structure of health care and health care coverage in this country, the next president and the new Congress will need to take the lead.

California Health Care Reform: The Prequel

Governor Arnold Schwarzenegger wasn’t the first state executive to try to expand health care coverage in California. He won’t be the last. The effort goes back at least as far as 1945 when then Governor Earl Warren sought to impose a payroll tax to cover workers’ and their families.

Steve Wiegand of the Sacramento Bee describes what happened to the Warren proposal. It’s worth reading as a reminder of just how tough health care reform can be. Back then, Governor Warren faced opposition from Labor, the California Medical Association and the Chamber of Commerce. It was branded by some as “socialized medicine” and wound up being killed in the Assembly Health Committee along with competing reform plans.

 While Mr. Wiegand doesn’t delve into whether the details of Governor Warren’s plans was frought with problems or the strength of the California’s economy at the time, there’s still enough parallels to the state’s recent debate to create a sense of deja vu.

Over the past year I’ve become convinced that any meaningful reform will have to be national in scope. States are simply too constrained in addressing a national problem to make much headway. If the new president fails to enact meaningful health care reform, however, the states will need to address the matter. Again. Hopefully whoever is governor of California at the time will have learned from Governor Schwarzenegger’s efforts. And from Governor Warren’s, too.

Lessons Learned: California’s Health Care Reform Effort

Health Affairs, a highly regarded public policy journal, has been conducting a thoughtful online roundtable concerning California’s unsuccessful health care reform effort in California. The insights are useful and well worth reading. With comprehensive health care reform moving to the federal arena for the next couple of years, whoever occupies the White House next year could learn a lot from the California experience.

The participants in the Health Affairs roundtable are all experienced public policy experts who were deeply engaged in California’s health care reform debate. Indeed, the roundtable’s only shortcoming is that all the participants were, to one degree or another, advisers to or supportive of Governor Arnold Schwarzenegger’s health care reform proposal. A more diverse panel would have been enlightening. Nonetheless, each of those involved were not only qualified, but offer meaningful insights. The panel was comprised of:

• Rick Curtis, President of the Institute for Health Policy Solutions(IHPS).
• Rick Kronick, Professor of Family and Preventive Medicine and an Adjunct Professor of Political Science at UC San Diego. He was also a Senior Health Care Policy Advisor in the Clinton Administration and participated in developing that Administration’s health care reform package.
• Patricia Lynch, Vice President of State Government Relations Services at Kaiser Permanente.
• Ed Neuschler, Senior Program Officer at IHPS.
• Lucien Wulsin, Project Director of the Insure the Uninsured Project. He was also the chief aide to Assemblyman Burt Margolin responsible for developing AB 1672, California’s successful small group heath care reform package passed in 1992.

Links to their postings, in the order presented, follow:

• “California Shelved Health Care Reform,” March 5, 2008, Curtis and Neuschler
• “Opportunity Lost: The Failure of California’s Health Reform,” March 5, 2008, Lynch
• “The Mandate Wars, In California and Beyond,” March 6, 2008, Kronick
• “California: Negotiating The Intersections of Reform,” March 6, 2008, Wulsin
• “Shared Responsibility: The Better Course,” March 10, 2008, Curtis and Neuschler
• “Guaranteed Issue? Only With An Individual Mandate,” March 10, 2008, Lynch
• “Coverage And Cost Containment: Both Are Needed,” March 10, 2008, Wulsin

For those interested (i.e., Mom), here’s a link to my post on lessons learned from California’s Year of Health Care Reform. It’s not nearly as erudite as the others, but hey, it’s my blog! <g>

Recissions, the LA City Attorney, and the Three Laws of Politics

The debate over health care plans cancelling policies for members who incur significant claims on the grounds that they omitted or misstated information on their original applications for coverage (a practice called “rescission”) is instructive. Few defend the right of consumers to lie on their applications. In addition, few maintain the carriers haven’t overreached in defending themselves from fraudulent applications. And no one claims the carriers have done a good job of presenting their case to the public on this issue.

In some of my speeches I talk about the three laws of politics I’ve developed over (too many) years dealing with campaigns, the press and politics in general:

• Law #1: The Law of Political Reality: Political Reality trumps Real Reality for all political parties at all times.
• Law #2: The Law of Political Activity: Politicians are paid to address perceptions and that’s what they do
• Law #3: The Law of Political Reporting: The media is paid to report on what politicians do and that’s what they do

The application of these three laws can lead to an echo chamber of surreal proportions. It often begins with the press reporting on a study or action by a company — let’s say questionable rescission practices by a major carrier. That’s what the press is supposed to do. Politicians read the article, perceive a problem and hold a press conference promising to address the problem. That’s what politicians are supposed to do. The press then reports on the press conference held in response to the press’ earlier article. Other politicians see that story, hold their own press conference and so on and so forth. After awhile it doesn’t matter what the original problem was, how widespread it is, or how nuanced it might be. The Laws of Politics do not suffer nuances.

This is the way issues become a part of the public’s consciousness. When real problem (and the problems surrounding abusive rescissions are real) and addressed by sincere politicians (there are more of them than you’d think), the process works great.

Some politicians, however, are more adept at applying the laws than others. Few would suggest that Los Angeles City Attorney Rocky Delgadillo is in the running for most adroit politician of the decade. He’s had several self-inflicted political mishaps that have shaken his credibility and weakened his future electoral prospects.

The City Attorney is astute enough to know the rescission issue has hit a chord with the public. And he’s clever enough to get his office engaged in the battle. Let’s give him the benefit of the doubt: he’s seen a problem, is sincerely concerned, and is seeking to address it.

Last week he sued Health Net for “engaging in unlawful and deceptive business practices” according to his office’s press release announcing the civil action (He is also initiating a criminal investigation against certain individuals at Health Net). The suit alleges health Net engaged in “unlawful, unfair and fraudulent business practices and unfair, deceptive , untrue and misleading advertising.” City Attorney Delgadillo claims he brought this action against Health Net because “[c]ountless Californians who believe they have insurance actually have policies that aren’t worth the paper they’re printed on.” I’m not sure what the legal definition of countless is, but it’s a lot. Never mind that less than one percent of health insurance policies are ever rescinded.

Using the unfair advertising laws in this context is an interesting legal theory. It’s awfully broad and, taken to extremes, could be abused. But there’s nothing wrong with a prosecutor — elected or otherwise — testing out a theory like this.

And testing it he is. Now City Attorney Delgadillo is turning his attention to Blue Cross of California. This time it’s not for the carrier’s rescission practices, but because the company issued a press release describing changes to its rescission practices. The City Attorney doesn’t believe Blue Cross, apparently because press releases are tools for burnishing a company’s public image and because, well, Blue Cross is an insurance company.

“In all of our dealings with the health insurance industry, our experience would lead me to have little or no confidence that the claims made by Blue Cross … are accurate,” he’s quoted as saying in an interview with the Associated Press. 

Leave aside the irony of an elected official whose official home page is not much more than a listing of the numerous press releases put out by his office publicly criticizing a company for issuing a press release. What’s more disturbing is that in the City Attorney’s mind, insurance company’s are incapable of telling the truth. City Attorney Delgadillo doesn’t claim his office has received complaints about Blue Cross not living up to the promises it made in the press release. It’s that, as an insurance company, the presumption is they’re lying.

That’s a sad statement about both, the low public standing the insurance industry has brought upon itself and the standards of fairness in the City Attorney’s office.

None of this should be taken as a call for the City Attorney to stop investigating insurance companies. But it does underscore that by adhering too closely — and inartfully — to the Law of Politics, the Los Angeles City Attorney is undermining the credibility of the office’s legitimate legal undertakings.

The State’s Role in Health Insurance Rate Increases

The first part of the year is when the cost of most health insurance policies increase. Most medical plans in most places are seeing rate increases far greater than general inflation. This raises legitimate questions about the sustainability of private health insurance pricing. Increasing faster than other prices means health insurance costs represent a larger percentage of overall spending. This, in turn, impacts the competitive position of American firms and the spending power of American families. That’s one of the reasons comprehensive health care reform needs to be high on the nation’s agenda.

In fashioning reforms, it’s important policy makers look at the complete picture. For example, comparing the rate of rising health insurance premiums inflation to general inflation is misleading. What drives health insurance costs is a complex mix of new technologies, an aging population, increased consumer demand and expectations, greater utilization of medical treatment, the cost of prescriptions in this country and a horde of other factors. Those required to defend health insurance rate increases (no one volunteers for the job) usually point to medical care inflation as a more appropriate benchmark than using general inflation. The problem with this defense is that, recently, premiums have increased at rates higher than medical inflation. This discrepancy was pounced upon by some legislators during hearings on health care reform in California this year. Clearly, the lawmakers implied, this is evidence of the industry’s lust for profits. What’s required, they say, is a governmental smack down. (OK, they didn’t actually use the word “smack down,” but premium regulation amounts to the same thing).

Before lawmakers get too carried away, however, they should look at their contribution to rising health insurance costs. Leave aside the costs related to mandated benefits, regulatory compliance and the like. Those are significant, but obvious. What’s less apparent is the government’s use of private insurance to subsidize public programs.

Medicare and Medicaid make up 55-to-60 percent of the average hospital’s revenues according to Richard Umbdenstock, president and chief executive of the American Hospital Association. As reported by the Todelo Blade, Mr. Umbdenstock said this would require providers to shift more costs to private insurance. In other words, when government budgets get tight, they cut back on what they pay doctors and hospitals to provide care to Medicare and Medicaid enrollees. Some of those providers reduce the number of such patients they’re willing to see — or stop serving them all together. That’s bad enough.

Others, however, shift the cost to those with private coverage. With more than half their income generated by government programs, it means a disproportionate amount of increase on private plans is required to make up for public cutbacks. If 60 percent of a hospital’s income flows from public programs, a 10 percent reduction in reimbursement rates requires increasing charges to private insurers by 15 percent. And that’s before increases based on medical cost inflation, general inflation or any other factors. It’s a rate increase entirely generated by governmental action.

This system actually works well for politicians. They get to cut government spending by undercompensating medical providers treating public program patients and they get to complain about “indefensible” rate increases by greedy private health plans. In other words, they get to pitch the problem, avoid having to catch it, and they can criticize the people that do.

Politicians who want to control both sides of the equation — cut back on public program funding and regulate private health insurance premiums – should be careful about what they wish for. Their own contribution to skyrocketing medical insurance premiums will be much more obvious. They’ll have to catch the problems they create  and they’ll be on the receiving end of the criticism, too.