Category Archives: Health care

Another Blow to Free Market Health Care

dpcby James A. Bacon

Citing fiscal reasons, General Assembly Republicans have blocked Medicaid expansion that would have extended medical coverage to 400,000 uninsured Virginians. But they have tried to enact other measures to make medical care more accessible and affordable. Among other ideas, they have fought for expanding medical clinics, rolling back Certificate of Need restrictions on competition, and pooling insurance company data to create databases that allow analysts to spot inefficiency and poor outcomes in the health care system.

This year, a bill sponsored by Del. R. Stephen Landes, R-Verona, would have eliminated legal ambiguities discouraging physicians from contracting directly with their patients to provide primary care services for a fixed monthly fee. The bill declared that the contracting arrangement, commonly known as Direct Primary Care (DPC), did not constitute insurance and, thus, was exempt from insurance regulation. DPC proponents say it provides a cheaper alternative to accessing primary care through health insurance, which adds layers of bureaucracy and cost.

But Governor Terry McAuliffe vetoed the bill last week, saying, “While I applaud the patron’s desire to increase access to care, I feel this concept needs further scrutiny and study. … Not only would a product like this deter an individual from purchasing health insurance, it would still not cover any catastrophic care or chronic conditions requiring a specialist.”

Landes’ bill passed the House 97 to 0 with broad backing from patients, family practice doctors, small business lobbies and chambers of commerce. But it ran into trouble in the Senate when the insurance industry began lobbying heavily against it. As reported by the Associated Press:

Insurance companies don’t oppose the idea of direct primary care in principle, but don’t want imperfect legislation rushed through, said Doug Gray, executive director of the Virginia Association of Health Plans. This legislation, he said, is unnecessary and provides no consumer protections.

McLaughlin has joined a tiny but growing movement of doctors nationally — there are only a handful in Virginia — who have begun to provide subscription-like service to patients, a model known as direct primary care.

Similar to concierge medicine for the rich, direct primary care can appeal to middle and low-income patients who struggle with high deductibles or can’t afford insurance at all. McLaughlin charges $60 a month for people over 31, $30 for 30 and under and $15 for kids whose parents are enrolled.

The change from typical primary care has been “wonderful,” McLaughlin said: She can focus on fewer patients, spend more time with each one, and worry less about dealing with insurance companies. Other doctors are taking notice, she says, including young ones, who might otherwise avoid going into primary care because of its relatively low profit margins and high-volume demands.

“This can change the trajectory of our whole system,” McLaughlin said.

That may be the real problem with Direct Patient Care — it would change the trajectory of the system. Many players in the health care industry are vested in the status quo and don’t want to see the system change, except on their own terms. And many politicians are so ideologically committed to an expanded role for government in health care that they want to grind out market-based alternatives before they can prove their efficacy. Meanwhile, legal uncertainties may discourage other physicians from following McLaughlin’s example, and Virginia consumers will be denied a choice that might benefit them.

Virginia 11th Best for Veteran Retirees

Source: WalletHub

Virginia scores a disappointing 11th place in WalletHub’s ranking of the “2016 Best & Worst States for Military Retirees” based on 20 metrics encompassing economic environment, quality of life and health care.

The Old Dominion racked up creditable 3rd place for economic environment (eight metrics including state taxes on military pensions and percentage of veteran-owned businesses, among others) and 4th place for quality-of-life (seven metrics including veterans per capita and percentage of homeless veterans). But the state scored a dismal 48th place finish for health care, which reflects five metrics including the number of VA health care facilities per number of veterans and recommendability of VA hospitals.

The impression created by the metrics is that veterans receive sub-par health care in Virginia. Whether that is a function of poorly run VA facilities or issues with Virginia’s broader health care system is impossible to deduce from WalletHub’s presentation. But it’s a question worth asking.

— JAB

More Visibility for Health Plan Mergers, Please

More sunshine -- always better

More sunshine — always better

by James A. Bacon

Virginia consumers are not particularly torqued about two proposed mergers between leading health care insurers — only 20% of respondents to a poll sponsored by Virginia Consumer Voices for Healthcare (VCVH) were even aware of the proposals — but that didn’t stop 87% from being “very” or “somewhat” concerned by the impending consolidations when told about them. So reports the Richmond Times-Dispatch.

Virginia Consumer Voices released the survey results as the State Corporation Commission and other regulatory agencies around the country study the impact of the mergers on competition in state health care markets. The consumer group and the Virginia Hospital and Health Care Association, among others, have expressed concerns that the mergers would reduce competition in Virginia, increase costs to patients and reduce innovation in the marketplace.

All four companies affected by the proposed mergers belong to the Virginia Association of Health Plans, which lists ten members. Anthem Blue Cross Blue Shield has proposed buying Cigna, while Aetna has proposed taking over Humana Health Insurance.

Virginia Consumer Voices says the mergers would create near-monopolies in certain segments of the health care sector:

These mergers would substantially reduce competition and create large overlaps in Virginia in a number of different insurance products including commercial, ASO, and Medicare Advantage. A combination of Anthem and Cigna would create an entity with just under 72% share of the Virginia ASO market, and a combination of Aetna and Humana would have 66% of all seniors with a Medicare Advantage plan in Virginia.

The mergers would also increase costs for consumers. The merging companies have requested significant premium increases within Virginia, and studies on health insurance mergers have found significant premium increases for consumers post-merger.

Anthem, the dominant health care provider in Virginia, has not been especially aggressive here in the Old Dominion in justifying the project. A website at www.betterhealthcaretogether.com seems more concerned with pitching the merger to shareholders than consumers.

However, in testimony before Congress, Anthem CEO Joseph Swedish argued that the role of health care insurers is changing.

Health care in our country is rapidly evolving, driven by the needs of consumers, who demand change from all sectors — providers and payers. … No longer is it enough for health insurers to serve as financial stewards in the health care delivery transaction; we must now assist consumers as they interact with the health care system. … We must go beyond paying claims, instead partnering with providers by offering human and financial resource support, actionable data analytics, and tools that further their efforts to focus on the health of their patients, while shifting from volume- to value-based payments. And above all, we must help all stakeholders — providers, consumers, employers and brokers — change from a system that has historically focused on sick care to one that promotes optimal health.

One driver of the merger is big data. Stated Swedish: “Anthem’s proposed merger with Cigna will result in the aggregation of useful information that can then be applied to bringing a better, more targeted product to consumers, and ultimately, improving the care that providers are able to deliver parents.”

Bacon’s bottom line: File this under “Eyes Glaze Over… But Very Important.” Every Virginian with private health care coverage, including Medicaid and Medicare plans administered by private companies, has an interest in the outcome. Health care costs continue to rise, and consumers should worry that industry consolidation will give insurance carriers more bargaining power in the marketplace and fatten their bottom lines. On the other hand, the only way to improve the quality of health care without bankrupting the country is through innovation — and private health insurers have plenty of ideas on how to change the system.

Virginia Consumer Voices and other groups are calling for the SCC to give the public a platform for airing diverse points of view. I agree. The more openness, transparency and public participation the better. We’re talking about the future of Virginia’s health insurance sector here. That’s too important to decide in the shadows.

The Graph Says It All…

physicians_v_administrators

Who has caused the explosion in health care costs since 1970? Physicians or runaway bureaucracy? This graph doesn’t leave much to the imagination. Hat tip Isaac Morehouse by way of Instapundit.

— JAB

Would the Suicide Epidemic Get More Attention if the Victims Were Women and Minorities?

Graphic credit: Wall Street Journal

Graphic credit: Wall Street Journal

When does a suicide epidemic become a national crisis? When women and minorities end their lives in greater numbers than men and whites, thus confirming the dominant narrative of a racist, patriarchal society that discriminates against all manner of oppressed groups… Until that time, the rising suicide rate will get only passing attention. Depending on the age group, according to new data, American men kill themselves at a rate four to ten times the rate of women. Whites also end their lives at three times the rates of African-Americans, Latinos and Asians.

In a society stained by “white privilege,” and “male privilege,” a strikingly large number of white males seem to think otherwise. Rather than basking in their advantages, they’re checking out in ever greater numbers. Reviled in the dominant narrative of our age as the oppressor, white males are the one group whose cultural mores reject the idea of victimhood and grievance mongering. Rather than interpreting the inevitable setbacks and vicissitudes of life through the lens of race, class, gender, the so-called “angry white male” is far more likely to direct his anger inward by means of suicide or outward in explosive, mass shootings and death-by-cop incidents.

Graphic credit: American Foundation for Suicide Prevention

Graphic credit: American Foundation for Suicide Prevention

While the right-thinking people are all caught up in the latest victimization drama — the trauma of transgendered people unable to use the bathroom of their choosing — the suicide epidemic receives very little notice. Sure, the problems of transgendered people are real, but c’mon, so are the problems of people whose lives suck so badly that they kill themselves.

According to the American Foundation for Suicide Prevention, Virginia’s suicide profile matches that of the nation (which should come as no surprise, because our demographic profile matches that of the nation). There were 1,122 suicides in Virginia in 2015 — 12.86 per 100,000 population, a hair below the national average. Suicide is the 11th leading cause of death in the state; more than three times as many people die by suicide here than by homicide.

Does anybody care?

— JAB

Virginia Obamacare Update

Anthem Healthkeepers, with 190,000 enrollees in Virginia, is filing for an average 15.8% hike in its 2017 Affordable Care Act premiums.

Innovation Health, with 61,000 enrollees, is seeking a 9.4% increase.

United Health, with 6,900 members, wants a 17.9% increase.

The overall weighted average increase request in Virginia, according to Investors Business Daily, is 17.9%.

I thought the cost curve for health care was supposed to bend downward, not upward.

–JAB

What Went Wrong with Long-Term Care Insurance?

Long-term care insurance information, form, Folders and stethoscope.

Long-term care insurance information, form, Folders and stethoscope.

by James A. Bacon

I am one of those schlubs who takes out insurance policies to protect against bad things happening. One eventuality I worry about is the need for long-term care. The longer you live and the more chronic conditions you develop, the greater the odds – about 50/50 for a 60-year-old today — that you’ll wind up bed-ridden at home or in a nursing facility. Feeling strong and fit at 53 when I took out a policy ten years ago, I was betting that I’d live longer than the average Joe and be more likely than not at some point in my life to benefit from having insurance. Signing up at a relatively young age would lock me in at an affordable rate. Or so I thought.

About two months ago I received a letter from my insurer, New York Life Insurance Company, informing me that my long-term care policy, which had remained stable ten years, was scheduled to increase 20%, costing me, in rough numbers, an extra $300 per year after a three-year phase-in. Three hundred bucks won’t bust the Bacon bank, but I was miffed — it was the principle of the thing. I had not been led to understand that my insurance rate would go up. And I bet there were other policy holders for whom $300 per year would cause real hardship.

Well, a look at my insurance policy indicated that, sure enough, New York Life was entitled to raise my fees. My bad. I should have read the fine print. Even so, any rate increase had to be approved by Virginia’s Bureau of Insurance, and I wondered — as I suppose an estimated 80,000 other long-term care insurance policy holders are wondering — what is the justification for jacking up our rates?

The letter referred vaguely to “longer life expectancies and an increased need for long-term care benefits.” Did the insurer mean to tell me that the people who are the world’s experts in demographic trends failed to anticipate that life expectancies would increase? And they miscalculated what percentage of the population would need long-term care? Really? That sounded lame to me, and I wondered if there was more to the story. In particular, I wondered if years of Quantitative Easing and low interest rates had depressed New York Life returns on insurance premiums below what the company had anticipated when it formulated the rates ten years ago. Could my higher insurance fee represent another $300 a year in tribute to Uncle Sam, just one of many ways in which low interest rates are invisibly transferring wealth from American citizens to its grotesquely swollen and indebted government?

One of the advantages of being a blogger is the ability to pick up the phone and call anyone with a decent chance that someone actually will answer. When I called New York Life to find out what the heck was going on, company spokesperson Terri Wolcott put me in touch with Aaron Ball, vice president and head of the Long Term Care business, who, as coincidence had it, lives in good ol’ Richmond, Va.

Low interest rates were a factor in the rate increases, Ball says, but not a decisive one. He candidly admits that the industry screwed up key underwriting assumptions.

We Underpriced the Policy. Sorry about That.

“When you apply for coverage, it can be 20, 30 or 40 years before you make a claim,” says Ball. “We set up reserves to pay claims 20 to 40 years in the future. We’re earning interest on those investments, and we assume what those interest rates will be.” Ten years ago, carriers were assuming earnings in the 5% to 6% range (conservative assumptions that were lower than what most pension funds were assuming at the time). “Today, they’re assuming in the 3% to 4% range. The low interest rates have put pressure on the portfolios.”

Higher returns on the company’s investment portfolios might have offset the negative experience, tempering the need for a rate increase, Ball says, but the bulk of the blame goes to actuarial miscalculations regarding other key variables.

Morbidity. The first the key variables is morbidity — how sick will policy holders get, and what will be the appropriate venue for treating them? When projecting 40 years into the future, getting this assumption correct can be harder than it looks. The things that put people into long-term care change over time. Ten years ago, frailty issues predominated — hip fractures, cardiovascular problems, and the like. Today, the driver is cognitive claims — Alzheimers and other forms of dementia. Also hard to predict is the setting in which people will be given long-term care. “Back in 1988, there was no such thing as an assisted living facility,” says Ball. As it turned out, New York Life’s morbidity assumptions were close to the mark. Other insurers got these assumptions wrong, and they’ve had to make upward adjustments in their premiums.

Voluntary lapse. When people buy policies, some continue to own the policy and eventually collect benefits, while others let their policies lapse voluntarily. The “lapsers” pay premiums that don’t get refunded, effectively underwriting the cost of the policy for others. When long-term insurance was getting off the ground about 20 years ago, there was no basis for determining how many policy holders would let their policies lapse, so carriers made the best guess they could. In most cases, those guesses were wrong.

New York Life assumed in pricing its premiums that policies would lapse at an annual rate of 2% after four years, but actual experience showed that the rate trended downward to about 0.5%. More people hung onto their long-term care insurance policies than the company expected.

Mortality. The rate at which policies lapse due to the policy holder’s death is another major variable. “We now expect twice as many people to be alive at age 90 compared to what was assumed when the product was priced,” says Wolcott. “Longer life expectancies generally result in additional claims because more people utilize long-term care services at older ages.”

The explanation made sense. I didn’t like it, but it made sense.  New York Life blew two of its key assumptions (though not as badly as many other insurers did) and low interest rates depressed investment turns. Accordingly, to maintain the actuarial viability of the policies, the company had to jack up rates.

But the explanation raises a new set of questions. If policy holders sign a contract with an insurance carrier to provide a certain set of benefits for a certain price, why isn’t the carrier obligated to eat the difference when they make bad decisions? I’ve never heard of carriers filing to reduce premiums if their assumptions turn out to be too optimistic. Maybe it happens, but I haven’t heard of it. No, they keep the profit. Given the way the incentives are structured, aren’t insurance companies encouraged to low ball premiums, knowing that they can come back later and jack up rates? Continue reading