Posted 2/1/12 on the Disease Management Care Blog
Approximately 15 years ago, the Disease Management Care Blog was a speaker at a conference with an audience mostly made up of managed care leaders. It boldly argued the nation’s disease management vendors were going to help put the nation’s health insurers out of business by simultaneously assuming risk and lowering costs.
Hows that for chutzpah. The DMCB was never invited back, but not because it isn’t an outstanding conference speaker who deserves fat fees.
It was because it was utterly wrong.
And so is this online commentary on accountable care organizations (ACOs) courtesy of the The New York Times. In it, Dr. Ezekiel Emanuel boldly predicts that by 2020, ACOs will drive health insurance companies out of business. They’ll do that by assuming full risk, dropping patient barriers to care, coordinating services, fostering communication, promoting health, banning fee-for-service, increasing efficiency, relying on evidence-based care, being locally responsive and competing against other ACOs on cost and quality
Dr Emanuel is being astonishingly overconfident for four reasons.
Continue reading “A Thousand Dollars Says Dr. Ezekiel Emanuel Is Wrong About ACO’s Long Term Prospects”
What could $15,000 get you?
$15,404 was the average annual cost of health insurance for a family of four with a PPO plan in the U.S. in 2011. The cost was fairly uniform across U.S. regions, with the lowest of $14,743 found in the West, and the high of $15,981 in the Northeast.
This health cost watermark finding was published in the always-informative annual Kaiser/HRET Survey of Employer-Sponsored Health Benefits for 2011. This study slices and dices the employer-based health insurance market across many dimensions, in terms of size of employer, type of employer, employee cost sharing, prescription drug plans, among other parameters.
Continue reading “Working for Health Care: What $15,000 Will Buy An American Worker”
First posted 8/26/11 on Health Populi
Health plans are more aggressively managing medical costs, leaning out administrative inefficiencies, and looking for new customers. Plans are undertaking these strategies as they face uncertainties over the next couple of years leading up to the full implementation of the Affordable Care Act, according to a paper from Boston Consulting Group (BCG), Innovation, Diversification, and a Focus on Fundamentals, looking at how health reform will change the insurance landscape.
Continue reading “Health Plans Enter A New World of Retail”
Vince Kuraitis and Jaan Sidorov
First posted 7/5/11 on the eCareManagement Blog
Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:
This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.
Continue reading “The 100 Year Shift? Introduction and Overview”
First published 5/11/11 on Health Populi
Health care costs have doubled in less than nine years for the typical American family of four covered by a preferred provider health plan (PPO). In 2011, that health cost is nearly $20,000; in 2002, it was $9,235, as measured by the 2011 Milliman Medical Index (MMI). To put this in context,
- The 2011 poverty level for a family of 4 in the 48 contiguous U.S. states is $22,350
- The car buyer could purchase a Mini-Cooper with $20,000
- The investor could invest $20K to yield $265,353 at a 9% return-on-investment.
Continue reading “Average Annual Health Costs for a US Family of Four Approach $20,000, With Employees Bearing 40%”
Brian Klepper and David C. Kibbe
First published 10/30/2008 on The Health Care Blog
Brian’s Note: Recently I received a note from a New Jersey primary care physician who argued that, even more than Medicare, the health plans are killing primary care through extraordinarily low reimbursements. He wrote:
Through state legislation and regulatory changes over the past 10 years commercial carriers are now routinely and consistently paying less than Medicare in New Jersey. Last year Aetna dropped to less than 65% of the local Medicare rate for a complex office visit. This year, in my county, CIGNA dropped to 51.5% for the same office visit, and that’s when the RUC, as flawed as it is, declared that 53.5% of the full Medicare rate was what the practice overhead should be. So now CIGNA is officially paying less than what the undervalued RBRVS system states is the cost of care.
To my mind, this type of reimbursement cannot be interpreted as anything else than an intentional effort to stifle primary care and it’s moderating influence over specialty, outpatient and inpatient excesses. While a robust literature – first by Barbara Starfield and more recently in Health Affairs – has nailed down that more primary care reduces risk and cost while improving quality, America’s health plans continue to pay primary care through volume-based reimbursement that functionally shortens office visits, increases specialty visits and diminishes our supply of primary care doctors.
David Kibbe and I asked about this problem this two and a half years ago. See below.
Sometimes a whisper is more powerful than a shout. Below is a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.
Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.
Continue reading “Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?”
First published 4/4/11 on Health Reform Update
A new study, reported in the American Journal of Managed Care, seems likely to add more heat to the continuing medical loss ratio controversy.
The Accountable Care Act effectively mandates that health insurers achieve MLRs of 85 percent for large group business and 80 percent for small group and individual business, with insurers not meeting these thresholds required to make rebates to affected policyholders. However, the ACA allows HHS to issue a waiver if the requirement would disrupt a state’s insurance market. So far, an individual coverage waiver has been granted to the State of Maine, with eight other states’ waiver requests being considered.
Continue reading “Medical Loss Ratios – Again”
First published 3/8/11 on Health Populi
“If nothing else, the health reform bill has signaled the beginning of the end of the health plan as we know and love it,” David Brailer, once health IT czar under President GW Bush and now venture capitalist, is quoted in Reuters on Hot Healthcare Investing Trends for 2011. One health plan Brailer called out that could be relevant in the post-reform, post-recessionary US health world is Humana.
I had the opportunity to spend time with Paul Kusserow, Chief Strategy Officer for Humana, during the HIMSS11 meeting. Our conversation began with me asking why the chief strategist for Humana would attend HIMSS.
Continue reading “The “Post Health Plan” Health Plan”
First published 3/2/11 on [Not] Running A Hospital
What will be the biggest trend in the health insurance business over the coming years? A tendency to shift risk from the insurance companies to the public.
How fitting for a sector that was created to manage risk to do this.
Why is it happening? Even before the recent health care legislation in the US, insurance companies were looking for a way to shift the rising cost of medical care to others.
Continue reading “Power – Er, No, Risk – To The People”
Originally published 1/06/11 on HealthBlawg
The current all-ACO issue of Health Affairs includes a piece by Jeff Goldsmith entitled: Accountable Care Organizations: The Case For Flexible Partnerships Between Health Plans And Providers. It is a proposal for how private sector health plans ought to pay for services, in order to save us all from what Goldsmith sees happening in the near future thanks to the Gold Rush mentality among health care provider organizations working to become ACOs before they’ve been defined in regulation.
Continue reading “Accountable Care Organizations: The Emperor Has No Clothes, Or, Jeff Goldsmith’s Plan B”
This sobering report arrived on my desk today. The International Federation of Health Plans is comprised of “the leading global network of the industry, with one hundred member companies in 30 countries.” Each year they prepare a report that compares pricing for common services.
Continue reading “International Federation of Health Plans 2010 Comparative Price Report: Medical and Hospital Fees by Country”