A Hybrid Health Care System: Good Politics; Unrealistic Policy

When it comes to topics as complex as health care reform, the legislative dance generally involves two steps.  The first focuses on educating decision makers. It’s a sincere effort to learn the facts, understand the options and identify the trade-offs. Yes, there’s a political element to this phase, but there’s more often a genuine desire to learn about the issue.

The second step in the dance is when the actual language is drafted. This is the phase in which partisanship dominates, where the goal is to win, not educate. Yes, compromises will emerge, and hopefully they’ll be informed by the educational phase that went before, but this is when decisions get made. Which means it’s when political muscle matters more than the ability to educate.

We’re still in the educational step — for now. But the step is coming soon and outlines of the political phase are becoming clear. As I’ve written before, one of the key issues will be whether there should be a government-run health plan competing with private carriers for consumer’s premium.   Proponents see this hybrid approach as a way to drive down costs while keeping private health plans honest. Opponents see it as a big step to government takeover of the health insurance industry.

The Lewin Group published a study today that bolsters the argument of opponents. Entitled “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options” the report attempts to quantify the impact a federal offering would have on private competitors (and on the income of providers). And that impact is substantial. The study assumes health plan offers coverage comparable to the Blue Cross Blue Shield Standard Option within the Federal Employee Health Benefit Plan (meeting President Barack Obama’s promise to offer all American’s access to the same coverage as members of Congress).  If this government competitor sets doctor and hospital reimbursement at the same level as is used by Medicare, the Lewin Group predicts over 131 million Americans would enroll — approximately 119 million of them shifting from private plans.

If the government alternative is made available only to individuals, the self-employed and small businesses the impact is significantly less, but still substantial.  The study estimates 42.9 million Americans would enroll in the government offering — 32 million of them moving from private plans.

While several factors were taken into account by the study’s authors, John Sheils and Randy Haught, the most impactful driver was cost. The theory is that the federal-plan would impose Medicare reimbursement rates on doctors, hospitals and other medical care providers. This gives the public plan a 30-to-40 percent premium advantage over comparable coverage offered by private carriers. The reason: as noted by in the study “payment levels for hospital services under Medicare are equal to only about 71 percent of what is paid by private health plans for the same service.” Indeed, this reimbursement rate covers “only between 92 percent and 95 percent of the cost of the services provided by the hospitals.” 

When it comes to doctors, the Medicare reimbursement rates are about 81 percent of that paid by private carriers.  The study assumes the public plan would have a further pricing advantage due to lower administrative costs resulting from there being no need to earn “insurer profit and insurance agent and broker commissions and fees.” But the big savings comes from the reduced claims costs.

Today, hospitals and other providers make up for the shortfall in revenue received for services to Medicare patients by increasing the fees charged to their insured patients. While this hidden tax raises the costs of premiums, it impacts on private carriers is somewhat equal. Since the Medicare population is distinct from the commercial market, the playing field remains level.

If the government were to step onto the field as a player, however, the dynamic changes. Now a competitor gains the pricing advantage — and that advantage would grow over time. As the public plan attracts more members, providers will see an increasingly negative impact on their income. The severity of the impact depends greatly on whether the public plan is open to all employers or only small businesses, the self-employed and individuals. If everyone has access to the public plan, the ability to shift costs to privately insured patients is greatly reduced. Under the latter scenario, providers could more than make up for the government’s underpayment by charging higher rates to large group insureds while also benefiting from a reduction in the number of uninsureds.

The likelihood, however, is that all Americans will have access to the public plan. President Obama has clearly linked health care reform to his economic recovery efforts. Large companies (think the auto firms) need the relief offered by the availability of a public plan — especially a public plan offering a 30-to-40 percent premium advantage.

The spiral would kick in rather quickly. As the public plan attracts more members, rates charged by private plans would go higher driving even more insureds to the government offering. Eventually, the only health plan standing would be the government’s.

Some might claim that the public plan would be unable — or unwilling — to use Medicare reimbursement rates. But why? The entire purpose of the government coverage is to drive down costs. Voluntarily paying providers more than Medicare would run counter to the governing agency’s mission.

There’s some caveats to this bleak scenario. It’s a good idea to be skeptical of all studies that estimate the future impact of unknown legislation. I’m not questioning the authors motivation or scientific rigor, but studies like this are, ultimately, educated guesses based on assumptions that may not come to pass and whose unintended consequences cannot, by definition, be anticipated.

Nonetheless, the study does raise the likelihood that the coming debate over whether there should be a public alternative available in the private market is the wrong topic. The Lewin Group Study underscores how difficult it will be for the government to maintain a level playing field while it competes on that field. And once the playing field begins to tilt in its favor, the result is inevitable: eventually the public plan will be the only player on the field.

So the debate is really whether Americans want a private health care system or a public system for all. There is no middle ground. The hybrid approach won’t last — eventually it will become a public system. So while the hybrid approach is attractive politically, it’s a false choice from a policy perspective.

There’s a legitimate debate to be had over whether the government should replace private carriers. That’s the debate lawmakers should have – especially while we’re still in the educational phase of the legislative dance. Calling for a mixed system sounds nice, but it’s not really an option. And health care reform is too important to debate fantasies.

Out-of-Network Scandal is a Good Thing

As they said in the 60s, “you’re either on the bus or off the bus.” Were Ken Kesey talking in a more modern medical context he might have said “you’re either in the network or out of the network.” And being out of the network can be costly.

Unlike HMOs, which are closed systems — your health plan covers treatment within their network or, with few exceptions,  doesn’t cover the service at all — PPOs are more open. You get a higher reimbursement for seeing providers within the health plan’s network or you get reduced coverage for services from non-network physicians. The benefits to all concerned are rather straightforward: the physicians and other providers offer the health plan lower rates in exchange for the health plan encouraging patients to see those providers. The health plan pays less so can offer their coverage at a lower cost, increasing their market share. Consumers pay less out-of-pocket when they use one of these preferred providers. Yet, if the consumer does seek medical care from a provider outside the network, the health plan pays a significant portion of the bill.

In theory, what the carrier pays for out-of-network services is a percentage of the usual, reasonable and customary (”UCR”) charges imposed by most providers in that community. That sounds fair: if a consumer chooses to engage a doctor who is more expensive than the norm, the consumer should pay for excess cost.

The problem is that few people know what the UCR cost is for any given treatment. Heck, physicians rarely know what the UCR is for their community for a particular service. When the carrier notifies the patient that their doctor charged more than what is typical it’s too late for the patient to do much about it. The result: angry patients, frustrated doctors and another deposit of ill-will in the industry’s karma account.

At the heart of the problem is defining “usual, reasonable and customary.” In the end, despite all the surveys and actuarial work, a high level of subjectivity is involved. How is it measured? Who determines if the costs are “reasonable” even if they are usual and customary. There’s a lot of wiggle room in the data base.

For years, the “decider,” as a past president would put it, for the nation’s largest health plans has been a company called Ingenix. Ingenix is owned by UnitedHealth Group, Inc., which also owns the health plan United HealthCare. Even though Ingenix is owned by a competitor, most of the major health plans in the country relied on its billing information for determining what out-of-network charges they would pay.

Not for long. New York Attorney General Andrew Cuomo went after Ingenix and UnitedHealth for manipulating reimbursement rates and defrauding consumers. As a result of Attorney General Cuomo’s actions, Ingenix will exit the billing database business and UnitedHealth will pay $50 million to help create a non-profit assigned to maintain a new, independent database.

While the New York legal action is no doubt painful to some carriers, most notably UnitedHealth, it could work to the industry’s benefit. It replaces a point of intense friction with an objective, common definition. It’s not that the definition of UCR put out by the non-profit won’t still be significantly subjective — it will be. But it will be the definition of the non-profit.  And it’s not that consumers won’t blame the health plans when they disagree with the non-profit’s definition of UCR — they will. But the carriers will be able to refer their members to the non-profit.

Given the low regard the industry is held in by the public, any action which stems that flow of ill will deposits is a good thing.

Of course, this being America, the path to better karma is not an easy one. The industry will first need to go through the political gauntlet of law suits and public hearings. Next in line: The Senate Commerce, Science and Transportation Committee.  It’s Chair, Senator Jay Rockefeller, is holding a hearing Tuesday in which executives from United HealthGroup and Ingenix will be the star witnesses. As reported by the Associated Press, Senator Rockefeller claims, UnitedHealth and Ingenix are “lowballing deliberately. They deliberately cut the numbers so the consumer as to pay more of the cost. … It’s scamming. It’s fraud.”

In that UnitedHealth has already paid $350 million to settle a suit on the matter brought by the American Medical Association, albeit without admitting guilt, the accusations are hardly surprising. And while UnitedHealth would like to put the UCR scandal behind them, there’s a script to these things and they tend to run through Washington. So this is just something they need to do. And it’s something they should do.

Because the UCR situation wasn’t fair to consumers. And if the industry needs to pay a price as part of fixing it, so be it. At the end of the day, there will be a more fair way of defining what out-of-network charges should be. And that’s a good thing for consumers, providers and health plans.

2009 versus 1993 Health Care Reform: The Difference is Consensus

Politically, 2009 and 1993 will share some similarities.  A new Democratic President takes over after years of a Republican White House. The new president will be able to work with a Congress firmly in Democratic control. Both soon-to-be President Barack Obama and then President Bill Clinton entered office during difficult economic times. And as candidates both made health care reform a top issue in their successful campaigns.

But 2009 is far different from 1993 in many ways. Concerning health care reform the political environment are strikingly different.  In 1993 President Clinton asked First Lady Hillary Clinton to take the lead. As I’ve noted previously, her insular and heavy handed approach helped doom that effort. But she had lots of help. There was broad disagreement about the nature of the problem, let alone the solution. Interest groups fought the Clinton Administration reforms vigorously and effectively. Given the lack of consensus and clumsy politics, it’s eventual defeat, in retrospect, seems inevitable. 

In 2009, the political environment will be far different. That there is a crisis in America’s health care system is broadly accepted. Out-of-control medical costs, and the ever increasing health insurance premiums they cause, are harming the financial security of families and the economic viability of companies. Tolerance for the large number of uninsured in the country is near an end.

There’s not only wide agreement that there is a problem, there’s a growing consensus on what the solution might be. The several proposals already circulating in Washington overlap with one another and the approach advocated by Candidate Obama. Interest groups and academics who waged pitched battles in 1983 are finding common ground as 2009 approaches.

This was strikingly clear in a recent broadcast of NPR’s To The Point. Host Warren Olney interviewed representatives from Families USA (generally considered a liberal health care reform advocacy group, America’s Health Insurance Plans (the carrier’s trade association),  the United States Chamber of Commerce and an academic from UC Berkeley. Their perspectives differed, but what was striking was the amount of agreement they expressed. True, there were no representatives of medical care providers on the show, but the common ground expressed by these four may not have been possible in 1993. And, as is usual when Mr. Olney is conducting the interviews, the show was very informative. (I recommend making the time to listen to this episode, entitled “Barack Obama and ‘Universal’ Healthcare Reform“).

Consensus in December 2008 does not guarantee a smooth and easy process to enacting comprehensive health care reform in 2009. The debate will be vigorous and heated. There will be winners and losers — and the losers will not take their lumps quietly. But unlike in 1993, when the top priority of many stakeholders was to stop health care reform, in 2009 their approach will be to help develop the right reform. Now that is a big difference.

Individual Health Insurance to Get Federal Scrutiny

Over 17 million Americans purchase health insurance for themselves and their families. Of the 47 million Americans uninsured during any year, academics project that six-to-twelve million could afford coverage, but either cannot obtain it due to their health conditions or choose not to purchase insurance. For argument’s sake, let’s say the market for self-purchased policies — generally referred to as individual coverage or, sometimes individual and family coverage — is around 20 million Americans.

That’s a substantial market. For years, however, it was mostly ignored. To be sure, consumer affairs and financial writers would publish their annual article on how to buy health insurance you’re self-employed. And health insurance agents certainly talk about the product. But for most people, the difference between individual and group coverage was of no interest. It was all “health insurance.”

That’s changing. First, because Senator John McCain and others, mostly Republican lawmakers, want to shift the nation’s health care system from one built around employers to one centered on individuals. Senator McCain’s health care reform plan calls for allowing “individuals to get insurance through any organization or association that they choose: employers, individual purchases, churches, professional association, and so forth.”

The second reason for greater attention being focused on individual insurance is the result of how some insurance companies have reacted to current market realities.  Since purchasing health insurance is voluntary, insurance companies need to protect themselves from those waiting until they’ve got claims in hand before buying. This means they require a health history from all applicants and accept only those posing an “acceptable risk.” In other contexts this behavior is understandable. No one expects auto insurance companies to sell coverage after an accident. No one expects insurers to sell a fire insurance policy after the house has burned down. Yet, surprisingly, many consumers — and policy makers — seem to believe that requiring insurers to sell medical coverage to individuals who have already scheduled their surgery is both financially and morally sound.

Some states, such as New York and New Jersey, require insurers to guarantee issue coverage to all applicants regardless of their health condition. Consumers in New York and New Jersey also pay premiums costing on average twice as much as those in Californians. But some carriers went beyond screening out high risks at the time they applied for coverage and instead sought to terminate the coverage when they used their insurance. The aggressive rescission practices of these carriers earned insurers tremendous criticism and ill-will.

The convergence of these two factors: the presumptive Republican presidential nominee seeking to expand the individual market and abusive rescissions by some carriers can have but one result: a Congressional inquiry. Democratic House Committee Chairmen John Dingell, Henry Waxman, and Frank Pallone have asked the Government Accountability Office to investigate the state of the individual health insurance market. They have also asked the GAO to look into the operation of state high risk pools which offer coverage to those unable to obtain private insurance.

In making their request, the Congressmen stated “The individual market for health insurance coverage is seriously flawed. Many people who need insurance and apply for it are denied coverage in the individual market or are offered insurance coverage that turns out to be inadequate or it is too expensive or both.” If this sounds like they already know what the GAO investigation will uncover, well, they do.

This makes the results from this Congressional involvement relatively easy to predict. Insurance company CEOs will be required to testify under oath concerning their rescission practices. The Committees will determine that the current individual marketplace underserves consumers by excluding those with existing medical conditions. And while the high risk pools are serving an important purpose, the committees will determine their coverage is too barebones and too expensive.

Next will come a call for guarantee issue in the individual marketplace and, if Congress is serious about real reform, that will mean a call for requiring that all Americans obtain coverage. And that, in turn, means a health care reform package similar to what’s being put forward by Senators Hillary Clinton and Barack Obama — and it might even be acceptable to a President McCain.

Of course, just because what’s coming is predictable doesn’t mean it’s wrong. It just means change is coming, regardless of who is elected president.

Senator Invites Carriers to Help with Health Care Reform

A coalition of Senators is waiting to help the next president forge a bi-partisan coalition on health care reform. A leader of the group, Senator Ron Wyden of Oregon, spoke before the America’s Health Insurance Plans 2008 National Policy Forum on March 5th and urged health plans to join the effort, not to fight it.

The 12 Senators, six Democrats and six Republicans, have their own health care reform proposal before Congress, the Healthy Americans Act. None of the Senators support every element of the package. But the mere existence of a bi-partisan coalition surrounding health care reform will give the next president a boost in developing a compromise plan.

In Senator Wyden’s address to AHIP, he said the “success of health care reform hinges to a great extent on how your profession responds to the efforts of a new president and a new Congress.” He warned, however, that if medical carriers spend ”millions of dollars fighting to preserve the status quo, you may delay reform for awhile but you will increase the likelihood of a government run health system with no role for the private sector.”

In urging the insurance industry to become a part of fashioning a solution, Senator Wyden noted that in a market in which 20 percent of Americans are uninsured, carriers need to be good avoiding risk. As Senator Wyden put it, “If you don’t excel at shedding risk, you are going to enroll too many people who need too much care.  Enrolling too many people who need too much care means that your costs are going to go through the roof.  When your costs soar this way, the healthy people that you do business with are going to start looking for another insurer whose costs aren’t going through the stratosphere.  In other words they’re going to look for another insurer who does a better job of shedding risk.”

This, according to Senator Wyden, is part of the reason the current health care system is broken. Another reason is that health care in the United States is tied to the employer/employee relationship, which the Senator noted hasn’t changed much since 1948. “But economic challenges for business and workers today are very different then they were in 1948,” he noted.  “Sixty years ago employers weren’t operating in a global marketplace and employees who went to work at twenty stuck around long enough to get a gold watch and a steak dinner for retirement.  Employers need cost-containment and workers need quality health care within a system that is portable – where they can truly take their insurance from job to job.”

As an alternative, Senator Wyden suggested carriers consider a new approach in which “everyone who’s not in the military or on Medicare, has a basic private health insurance policy. Private insurance companies are on the same footing – each must take all comers. Competition would be based on price, benefit and quality.”

This is the underlying approach established by the Healthy Americans Act. In asking his audience to consider supporting the legislation, he cited six reasons why health plans would benefit from this alternative system:

1. Bringing the 47 million uninsured into the system would greatly expand the private insurance market.
2. There would be “no competitive disadvantage for carriers doing the right thing” and, with a risk sharing mechanism as part of the package, there would be no need to specialize in risk avoidance.
3. The legislation supports increased information and transparency in the health marketplace.
4. By focusing on wellness and preventive programs, carriers would be selling a product people want more of.
5. Carriers “wouldn’t be the political football any longer.”
6. More attention could be given to cost containment issues such as reducing needless medical errors.

He concluded his speech with a plea to carriers to be a part of the solution. “I want to ask you to become a part of the Senate’s bipartisan effort to fix American health care. Both Democrats and Republicans in the Senate want to work with you to get health care right in 2009.”

My take on all this is that the stars may be aligning for a health care reform effort that is more consultative than adversarial. Senator Barack Obama has certainly spoken of the need to have everyone, including carriers at the table. Senator Hillary Clinton has also spoken of leading a more open process than she did during her husband’s Administration. Significantly, Senator John Edwards, who promised to exclude the health insurance industry from participating in the health care reform debate, is out of the race.

I also think a move away from employer-provided coverage is likely to be a strong current in future health care reform discussions. Senator John McCain favors this approach as does the bi-partisan coalition of Senators backing the Healthy Americans Act. The business community would love to be relieved of the burden of shouldering the nation’s health care system. In speeches I began giving in 2006 I predicted that health care coverage might follow the path of pensions. Instead of companies running pension plans they moved to simply administering — and contributing to — their employee’s individual retirement plans. Similarly, employers could administer — and contribute to — employee’s individual health plans. Even though the Democratic presidential candidates still embrace an employer-centric system, the support fora more individual-centric model is gaining momentum..

For health plans this could be good news. They would remain a core part of the nation’s health care system. While the nature of their competition would change, it would still likely be a vibrant, primarily private, market.

The role of health insurance agents could change far more dramatically. If consumers are pushed into exchanges, connectors or purchasing pools, the system administrators might assume they can play the role of agents. It will be important for agents to make sure Americans continue to have access to independent advocates and consultants — in other words, to professional insurance agents. That won’t be easy. Many lawmakers — and even more of their staffs — have never worked with an agent and don’t understand the value we bring to the system.

Senator Wyden and others, however, have expressed a willingness to listen to others. That’s an opportunity agents need to seize. Fortunately agents have a compelling story to tell. 

Hospital Cost Disparity Study: Implications for ABX1-1

The press is abuzz with the news that there’s a wide disparity in what different California hospitals charge for providing the same services. The study found that hospitals sometimes charge more than they need to in order to maximize their profits (or, for the non-profits, retained earnings). It seems hospitals charge what they can get away with. Amazing! (For examples of the coverage the report is receiving, take a look at what the Los Angeles Times, the San Jose Mercury News, San Francisco Chronicle, and the Kaiser Family Foundation’s KaiserNetwork.org web site have to say about it.) Not to fan the flames further, but there are also studies out there that show there’s no correlation between the cost of services and the quality of the outcomes.

The new hospital cost study was sponsored by the California Public Employees Retirement System (Cal-PERS) and the Pacific Business Group on Health (PBGH). Pardon my lack of surprise at the findings, but the findings are kind of old news. Health plans have been making this point since at least the late-90’s. Their claims were generally dismissed as mere justifications for rate hikes, but the facts have been out there for a long time.

There’s a host of reasons for these disparities. For example, there’s the impact of consolidation among hospitals. Community-based hospitals got tired of having their pricing requests ground down by carriers representing substantial numbers of potential patients. They realized the need for some heft of their own and consolidation was a way to get it fast. When the M&A activity settled, some hospitals were the only game in town — literally. This not only helped those hospitals negotiate higher reimbursements, it helped their chain as well. If a carrier wants a contract with the only hospital in City A, it might have to offer a sweeter deal to that hospital’s sister facility in City B. The result: higher hospital costs and, consequently, higher premiums.

Cal-PERS and the PBGH have done a public service by recognizing this market dynamic and having the credibility to draw attention to it. And anything that reminds policy makers that the key driver of health insurance premiums is the underlying cost of care is a very good thing.

What the study does not do, in my mind, is validate the need for a state-run purchasing pool as is called for by Assembly Bill X1-1, the compromise health care reform bill promoted by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez. Yet some see the study as confirming the need for the state to gin up its own activities as a health insurance buyer to negotiate with carriers. This is the public policy equivalent of 1950s Japanese monster movie. When Mantra invades, the government calls in Godzilla to fend him off. Of course, the city gets trampled in the process (or at least a cardboard facsimile of the city gets trampled), but in the end, these citizens who survive are assumed to be winners.

I have a great deal of respect for the folks at Health Access. I appreciate the thought they put into their positions even when I disagree with their conclusions. Yet I was surprised to see them play the Godzilla card concerning the purchasing pool. A recent post on the Health Access blog claims the hospital cost study underscores “why AB x1 1 has a purchasing pool–bigger than CALPERS–to negotiate the best possible deal with insurers and drug companies.” But the ABX1-1 purchasing pool won’t be negotiating directly with hospitals. They can hang tough with carriers all they want, but it won’t begin to touch the problems cited in the study.

In fact, several California carriers already have roughly as much, if not more, purchasing power than the state-run pool is likely to have and have long used it to try to negotiate lower prices for their members. (As noted in an earlier post, another study estimates the government-run pool ABX1-1 seeks to create would provide coverage to about 2.5 million Californians.) Ironically, when carriers leverage their purchasing power in this way, they’re sometimes condemned for it. The reality is, however, that in a seller’s market — where there are monopolies or near monopolies, for example – purchasing power isn’t very, well, powerful.

Nor is it clear how successful a purchasing pool will be in negotiating down insurance premiums. The California HealthCare Foundation has studied the performance of several such arrangements around the country. They conclude that ”a voluntary purchasing pool will not automatically reduce premiums.”   

The last time the state created a government-managed pool was as part of the small group health care reform package passed in 1992 known as AB 1672. That legislation created the Health Insurance Plan of California (HIPC). The HIPC was later transferred to  … wait for it … the Pacific Business Group on Health which renamed it PacAdvantage. It failed to reduce costs or to remain competitive in the marketplace and is out-of-business.

The hospital cost study is an important contribution to the health care reform debate. It underscores the need to rationalize spending with outcomes. To claim it justifies the creation of a state-run purchasing pool is too far a stretch.

2007 Prediction Results

On January 2, 2007 I was foolish enough to post some predictions for the year. At the time I promised to review my results in a year. And here we are, a year later. Just keep in mind these were predictions. I wasn’t saying these things should occur. I was predicting they would occur. 

2007 Prediction #1. More Major Carriers Will Enter the California Individual Health Insurance Marketplace
The theory was sound. The individual health insurance market in California is huge. And with employers dropping coverage it has been getting bigger. Major carriers (I mentioned Humana and Cigna) couldn’t ignore the potential here. And they still can’t, but they certainly didn’t act on it in 2007. My guess is the health care reform debate created enough uncertainty that, combined with opportunities in other state, made California less attractive. In fact, a carrier, Nationwide, left the California individual medical market. So while other carriers might get here eventually, this prediction was a big miss.

2007 Prediction #2. Carriers Will Experiment With New Distribution Strategies
The premise of this conjecture rested on carriers recognizing that online sales weren’t enough in the indivdiual insurance market segment. While that channel would grow in 2007 (see prediction #8) I sensed a countervailing trend to get more people in the streets talking about individual medical coverage. So I predicted a carrier (didn’t know which one) would supplement its independent agent channel and launch a captive field force. Agents wouldn’t like it, but some carrier’s need to increase market share would drive them to at least experiment with this approach. Turns out 2007 was not a year for carriers to be upsetting agents. In fact, all of the carriers have reached out to agents and their association, the California Association of Health Underwriters, for input and help on health care reform issues. Chalk this up as another miss.

2007 Prediction #3. A Carrier Will Try to Introduce Per Member Compensation
Tying agent compensation to the cost of health care doesn’t make much sense, yet the historical practice of paying agents a percentage of the health insurance premium pay has deep roots. Like many traditional practices they’re hard to change. I thought 2007 would be the year one of the major health insurance carriers would take a stab at it. I was wrong. The desire not to upset their relationships during the health care reform process may have influenced this, or it might be that none of the carriers thought this was an important enough issue to address. In any event, this is clearly miss #3.

2007 Prediction #4. Kaiser Will Seek to Work Closer With Agents in the Individual Market
Kaiser has been thinking about ways to work with independent agents since their small group team successfully added this distribution channel. With Tom Carter and Mitch Ross, among others, in leadership roles there, I felt 2007 would be the year they’d actually move forward with an agent channel. I’m sure they’re still considering it, but their deliberations — which can seem endless even to those inside Kaiser — are ongoing. Sensing a trend here? Strike 4.

2007 Prediction #5. No Major State Health Care Reform in 2007
I launched this blog thinking it would deal with health insurance related topics, but in a general way. That it came to focus on health care reform (to the extent that I renamed the site) was a gradual process. In hindsight it’s kind of interesting (at least to me) that it wasn’t until the fifth prediction that the topic of health care reform came up. Here’s the full text of that forecast: “This is a cheap prediction. While health care reform is at the top of everyone’s agenda in Sacramento, the issue is too big and complicated, there are too many stakeholders involved with too many diverse perspectives, and there are too many other pressing issues demanding attention for the Governor and Legislature to work things out in one year. But watch out for 2008.” Less of a “cheap prediction” than I imagined, but it turned out to be right nonetheless.

2007 Prediction #6. Mandates Become Viable
The idea here was that acceptable health care reform would require reducing the number of uninsured. This would mean requiring all residents to obtain coverage and that, in turn, would mean requiring all carriers to sell coverage to all applicants. These twin mandates were are key components to the health care reform package currently awaiting Senate consideration. And they’ve been a big part of the debate for most of the year. Clearly, mandates are viable. Hit #2.

2007 Prediction #7. More Musical Chairs in Carrier Organizations
There was a lot of changes occurring in the leadership of health plans around this time last year. In this prediction I noted, for example, that Lisa Rubino, had recently left as CEO of Blue Shield’s individual, small group and government program division and would no doubt be recruited quickly. Shortly after this post, Ms. Rubino was named president of Molina Health Plans in California. And while fewer moves among the carriers took place than I was thinking when I originally wrote this one, there were a number of changes. Since I’m the one giving out the scores here, I’m going to count it as a hit — but only barely.

2007 Prediction #8. Online Sales Will Continue to Grow
This was the gimme of the lot. The trend of independent agents to move a portion of their sales online is growing. The top producers for virtually every carrier sell exclusively or mostly online. Internet-assisted sales is a permanent part of the individual health insurance landscape. Its influence on small group sales is growing as well. I still believe that local agent who get to know their clients do a better job of finding the right health insurance plans for a particular consumer’s unique needs than any web-based sales site. But I also believe local agents should integrate the Internet into their sales process. Anyway, this was an easy prediction to get right, and I did. So that makes hit #4.

The tally reads four hits and four misses. My prediction skills are either half full or half empty, depending on your personality type. Significantly, I missed on all the predictions dealing with carrier competition, but got both of those involving health care reform right. Narrowing the focus of this blog to health care reform-related issues was a good move.

Blue Cross of California

First, full disclosure: I was a Senior Vice President at Blue Cross of California, or its parent company WellPoint from September 1997 through November 2005. While my precise responsibilities varied during those eight years, they centered around helping the company grow its Individual and Small Group business. Before joining and since leaving WellPoint, I’ve continued to work with Blue Cross while also having the pleasure of working with its competitors. I greatly respect those carriers, for many of the reasons I respect Blue Cross.

But it’s Blue Cross that has been in the news so much since I started this blog. Yet I’ve purposefully avoided posting on its situation and probably won’t post on it again. It’s too much of a no-win situation for me. If I’m too supportive, then I’m just being defensive. If I’m too harsh, I’m misusing my former insider status.

However, with the Department of Managed Care holding hearings on Blue Cross yesterday, and so many readers knowing of my affiliation with the company, I thought it permissible to make an exception. But this won’t be a post about the the substance of the charges. It’s more personal in nature.

I view the public pilloring of Blue Cross by the Department of Managed Health Care with mixed emotions. I enjoy seeing big companies brought to task as much as the next guy. It’s like watching toothpick thin famous-for-being-celebrity-types doing perp walks. Or watching bombastic politicians busted for the behavior they publicly decry. There’s a karmic aspect of it all that we humans seem to enjoy, the reasurrring balancing of forces in the universe.

So seeing a regulator take Blue Cross to task doesn’t bother me. It’s a part of the process. What prompts me to write, however, is how all this impacts the people of Blue Cross who have accomplished over the years.

The individuals representing the company at the hearing are friends and former colleagues of mine. I’ve seen them at work. Yes, it’s true they paid attention to the bottom line. That’s how any enterprise — for-profit or non-profit – stays in business. But I’ve also seen them striving to do the right thing for their members when no one outside the company was watching. I’ve seen them invest sweat, time and resources to improve customer service. I’ve seen how hard they’ve strived to create new ways of helping those with serious diseases improve their quality of life and medical outcomes. I’ve seen the efforts they’ve made — and the risks they’ve taken — to bring to market products which provide strong coverage at the lowest possible price in the face of skyrocketing health care costs.

Blue Cross is not a perfect company. There are no perfect companies — nor perfect people or government agencies, for that matter. They’ve made mistakes and where those mistakes violate law or regulations they should be appropriately punished. Further, Blue Cross has made their situation worse over the years by sporadically descending into moments of hubris and arrogance — and sometimes just plain public relations mindlessness. They’ve also taken risks to make things better, which means at times, they’ve failed and made things worse.

But Blue Cross of California is no Enron. There aren’t people there conspiring to rip off the innocent. It is a company by and large of people trying to do a good job for their members, their business partners and yes, their shareholders. (Traits they share with most of their competitors and respected companies everywhere).

Few things in life are clear cut. There’s a context and subtlety that gets overlooked in the circus-like atmosphere of a public scolding. Maybe every business and every industry needs to go through this now and again. When done right the results can be positive change. At worse, the hot water may help keep the enterprise humble. It’s just a shame that in the process, the people which make up the company and who are trying to do the right thing, can get scalded along the way.

2007 Predictions

Having started this blog on January 2nd, it’s almost mandatory to post a list of predictions for the coming year.  So here it goes:

1. More Major Carriers Will Enter the California Individual Health Insurance Marketplace
Expect to see Humana, Golden Rule and maybe even CIGNA making serious efforts to capture a share of the market while current players increase their investments here. Why? The individual and family insurance market segment is too large a prize for serious national and regional carriers to ignore — even those who think of themselves as “big market” carriers. Nationally over 17 million Americans under the age of 65 purchase their own coverage. Another 12 million of the uninsured can, according to academics,  afford coverage. That’s a lot of potential membership — and premium. Too much of each for carriers hungry for growth to ignore.

2. Carriers Will Experiment With New Distribution Strategies
Reaching this market can be a challenge. Most agents focus on group sales and distribution costs are expensive. Meanwhile, carriers are worried about the aging agency population. The “old days” of having life carriers recruit new agents, train them, and then watch as they migrated to selling health insurance are pretty much gone. So in 2007 watch for a leading carrier to introduce a captive sales force. (And no, I don’t have any idea which one). Some of the insurers already have captive phone-based agents and some already deploy captive field agents outside of California. All of them are nervous about agents’ reaction to a move like this. But one of them is likely to seek an “edge” and take the risk. They’ll try to shift attention to Kaiser distribution strategy, which is very reliant on direct sales, but I’m not sure this will help them. 

3. A Carrier Will Try to Introduce Per Member Compensation
Distribution costs are an expense carriers watch very carefully. Because commissions are based on a percentage of the premium, agents receive a raise with every rate increase. A flat per member (or contract) fee, on the other hand, is an appealing alternative. Some carriers have introduced this in other states, but only Kaiser has been able to make it stick here, primarily because their distribution focus is on direct sales. The risks of this approach is high, but the lure of gaining a cost advantage on the competition is likely to be too much for one of the carriers (again, I don’t know which one).  

4. Kaiser Will Seek to Work Closer With Agents in the Individual Market
Kaiser has a mission: to deliver excellent health care to its members at the lowest possible cost. This has meant keeping distribution costs to the bare minimum. Which has meant focusing on direct sales and offering agents only token compensation for bringing them clients. However, their experience in the small group market has shown they can do both — keep costs low while paying a competitive commission. There are several Kaiser executives who have worked successfully with agents, for example, Tom Carter and a recent recruit, Mitch Ross, formerly of Blue Shield. They understand the value of agents. And with new entrants to the individual market (see prediction #1), now is the time to reach out to agents. It won’t be easy for them to come up with a workable formula. But they’re smart and they’re motivated. This could be the year.

5. No Major State Health Care Reform in 2007
This is a cheap prediction. While health care reform is at the top of everyone’s agenda in Sacramento, the issue is too big and complicated, there are too many stakeholders involved with too many diverse perspectives, and there are too many other pressing issues demanding attention for the Governor and Legislature to work things out in one year. But watch out for 2008.

6. Mandates Become Viable
Health care reform that doesn’t bring down the number of full-time uninsureds won’t be viewed as meaningful reform. Yet too many Californians choose to avoid buying coverage (until after they have a need for it, of course). To get more dollars into the system, expect a mandate to be a big part of the health care reform debate. Personally, I can support this, but what terrifies me are how lawmakers and regulators handle the implications of this approach. Consider: if the government requires people to buy insurance then carriers must be required to accept all comers. And acceptable minimum coverage needs to be defined. Someone in Sacramento will call for regulation of the cost of this coverage. Which means they’ll want to regulate loss-ratios and distribution costs, too. It’s a slippery slope which, if not handled correctly, could have dire, unintended consequences for consumers, health insurers and health insurance agents.

7. More Musical Chairs in Carrier Organizations
We’ve seen a lot of changes lately at a lot of carriers. Expect more. With new carriers entering the market the demand for strong leaders with a proven track record and strong relations with agents will dramatically increase. And there’s a lot of good talent available. I haven’t talked to her lately, but I bet Lisa Rubino’s phone is ringing. 

8. Online Sales Will Continue to Grow
eHealth, Inc.’s recent IPO demonstrated Wall Street’s belief in the future of online sales, at least in the Individual and Small Group markets. Personally, I’m making a strong bet on this distribution channel (just visit www.InsuranceNeighborhood.com to see what I mean). But it’s the increasing number of independent agents moving online that points to growth in online sales. Thousands of agents in California alone have the ability to sell medical plans online. And consumers are buying online at increasing rates. They like the ability to quickly compare rates and benefits from a variety of carriers and to shop anonymously and to do all this at all hours of the day and night. Of course, I believe they also want to have a local expert available to them to help assure they find the right plan. That’s at the heart of the Insurance Neighborhood approach. My prediction: consumers will want the best of both worlds. Which argues well for not only my company, but for every local agent who sets up a robust sales site, too.

So here they are, nothing profound or too whacky. Some of them quite obvious. The list could be a lot longer, too, but, eight will do. A year from now I’ll dust these off. If they all turn out to be true, expect to see a self-congatulatory posting on this blog. If they turn out wrong, well, hopefully I’ll have figured out how to delete postings by then.

In the meantime, I’d be happy to post your predictions. Just send them my way.