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What does ‘insurance’ mean here?

Timothy Jost writes in Health Affairs:

“Some of the ACA replacement plans currently being considered by Congress would offer tax credits for the purchase of health insurance but do not specify the benefits that this insurance would have to cover or how extensive that coverage would have to be. The task of defining qualifying health insurance coverage would be left to the states.

“In evaluating health reform proposals, the CBO has traditionally projected how many people will be insured under the proposals. But if reform plans offer no single definition of coverage, the CBO cannot evaluate how extensive coverage will be under the reform plan’s terms. To make any meaningful estimate for comparing alternative proposals, the CBO must have a single definition of coverage. Otherwise, a proposal offering a small tax credit that might allow individuals to purchase coverage with very high deductibles or very low annual and lifetime limits, or that covered very few services, could be counted as covering just as many or more people than the ACA, which only permits comprehensive coverage in the nongroup market.”

To read more, please hit this link.

The monetary pleasures of insiders in America’s corrupt health-insurance system

This piece by Vatsal G. Thakkar, M.D., should be required reading for  healthcare-sector executives, clinicians and federal policymakers. It details how well-connected people, including physicians, can pull strings to get insurance coverage that ordinary people cannot.

He tells stories that “reveal an uncomfortable truth: Our health-insurance system is so broken that pulling strings — or rank — is sometimes the only way to get the coverage you think you’ve paid for.”

He continues:

“These workarounds are necessary because the healthcare system doesn’t follow any rational rules of economics, where the customer should be king.

“Economies of scale are supposed to bring costs down. But in healthcare, large hospitals are often more expensive than smaller ones because they can demand higher payments from insurance companies, which are then passed down to patients.

“In most realms, those with the least ability to pay should receive the biggest discounts. In healthcare, it is often the uninsured and indigent who receive bills with the full ‘chargemaster’ fee — the wildly inflated prices that nobody really pays — while large insurance companies get the biggest breaks.”

He discusses eloquently the lack of transparency in pricing —  an opaqueness that’s highly profitable for providers and insurers and so is likely to continue indefinitely — but bad for patients and their families. He notes:

“In a battle of dueling bureaucracies, the Supreme Court recently dealt a blow to price transparency in Vermont, where the state wished to publish a database of fees and other information. An insurance company, Liberty Mutual, objected to turning over the data on what it paid doctors and hospitals, and the Supreme Court agreed. The justices argued that, according to the ACA {Affordable Care Act} only the Department of Labor, and not individual states, had the right to collect this data. The ruling affects almost a dozen states that are pursuing similar initiatives.”

To read Dr. Thakkar’s essay, please hit this link.

When healthcare lines become blurred


Lennox Hill Hospital, in Manhattan’s Upper East Side.

This  HealthAffairs blog post by Michael Dowling, president and CEO of   Northwell Health, which serves metropolitan New York,  stems from  “The New Health Care Industry: Integration, Consolidation, Competition in the Wake of the Affordable Care Act,” a conference held recently at Yale Law School’s Solomon Center for Health Law and Policy.

Among his remarks:

“Today, the lines delineating the many different stakeholders in the health business are increasingly blurred. Providers are becoming insurers and insurers are becoming providers. To achieve success in this new paradigm, all of us need to work more collaboratively, with the overarching goal of keeping people well and delivering care more appropriately to those who do get sick or injured. We need to provide people access to better, more-affordable care — outside of the hospital. To offer and manage care across the full continuum, you have to innovate and bring resources and pieces together to address the holistic nature of the person’s condition, not just the episodic nature of illness.”

“As president of the largest health system in New York, I am in the ‘health’ business. By default, that means I am also in the ‘hospital’ and ‘ambulatory services’ business, the ‘insurance’ business, the ‘education’ business, and the ‘research’ business, among others. That’s because all of these pieces contribute to the continuum of providing better health to the communities we serve.”

“We are also partners in an insurance company. People ask, ‘Why did you want to get into insurance?’ Like, somehow, we let the fox into the hen house. The answer goes back to being in the ‘health’ business. We want to have as much control as possible over the premium dollar so that we can manage people’s health and not just manage people’s illnesses. That way, when we reduce the utilization in a hospital, we get to keep some of the savings.”

“The old model was a terrible misalignment of incentives. We could do wonderful things to reduce hospital utilization, but if the insurance companies got the savings and left hospitals with the cost, where did that leave providers or their patients? By effectively being in the ‘insurance business’ and partnering in an insurance company, we can more appropriately align the incentives.”

“When I am asked what Northwell Health wants to be in the long term, my answer is: ‘I want to be in the health business, the health-promotion business, and the wellness business, as well as the illness care business. I want to be able to do all those things well.”’



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