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Winners and Losers – Strategy in a Post-Reform World

Kramer

Most health policy experts are focusing
on the daily ups and downs in the political battles over health reform.
Within the health care industry, however, there is a
buzz
about who will be
the winners and losers after health reform passes.  A.M. Best’s U.S. Health and HMO Insurance Index has been
volatile since last November, reflecting high uncertainty about the
effect of health reform.  Earlier this summer, there was some speculative
analysis about the potential impact
of reform
on health care stocks.  Will health insurers come out as winners?
What about hospitals, doctors, drug manufacturers, and insurance agents?

It’s good to look ahead, but I think
most people are asking the wrong question.  Each of these health
industry sectors – in aggregate — will probably do just fine in the
post-reform world, as Bob Laszewski points out in his recent blog post.  The more important question is: who
will be the winners and losers within each sector?

Change is coming.  After all of
the political maneuvering this fall, some kind of health reform bill
is likely to pass.  The basic shape of the post-reform world is
coming into focus, and it is likely to include:

  • Insurance reform: guaranteed
    issue (no medical screening), along with rating rules and standardized
    benefits in the individual and small group markets.
  • Broader coverage: expansion
    of Medicaid, subsidies for low-income people and an individual mandate.
  • New market structures: an
    insurance exchange for individuals and employees of small groups.
  • Cost containment: increased
    attention to costs, transparency and accountability for insurers and
    providers.
  • Payment reform: a gradual
    shift from fee-for-service to bundled payments, as well as incentives
    for quality outcomes.
  • Emphasis on prevention,
    primary care, chronic disease management, and the use of comparative
    effectiveness research.

These changes in the regulatory and
market environment will create changes in the dimensions of competition
within the health care industry.  In the PRW (post-reform world),
health insurers and providers will require different skills and strategies
to be successful.

Health Insurers: In the
past, the key to financial success was risk management, i.e., making
sure that the expected medical costs of enrollees were predictable and
not too high.  Insurance CFOs focused on the “loss ratio” —
medical claims payments as a percentage of premiums – as a key measure.
Insurers used medical underwriting, targeted pricing and benefit design
to manage the risk profile of their enrollees.  Many insurers also
tried to hold down medical costs and administrative expenses, but it’s
much harder to do that.  (No one likes being yelled at by doctors.)
Most insurers have deep expertise and experience in risk management,
so it’s not surprising that this would be the primary tool for achieving
their financial goals.

In the PRW, however, the usefulness
of risk management tools will be greatly diminished.  Medical screening
won’t be allowed, and insurers will be limited in their ability to
use pricing and benefit design to attract only low-cost enrollees.
Even if they do, risk equalization mechanisms within the new health
insurance exchange will reduce the financial benefits of cherry picking.
Insurers will need to put more effort into managing expenses, for both
administration and medical services.  In other words, insurers
will need to move from risk management to cost management.

The second major change for insurers
will be in the small employer market segment.  In the past, insurers
focused on the employer as the customer, not the employee.  They
worked through brokers to get access to employers, to whom they offered
coverage on a sole source basis.  Insurers – rightly concerned
about adverse risk selection in a multiple choice arrangement within
a small pool – insisted on being the only health plan offered within
a small group.  The employees could only join the plan offered
by the employer, so there was little need for consumer-oriented marketing.

In the PRW, the employees of most small
businesses will purchase their coverage through a health insurance exchange.
The employer will have a minimal role, and the employee will have a
choice of multiple health plan options.  Insurers will need to
focus their sales and marketing efforts to consumers rather than brokers
and employers.  In other words, insurers will need to shift
from employer-based to consumer-based marketing
.

Health Care Providers:
Hospitals and physicians face similar changes.  The analogy to
insurers’ risk-management strategies is providers’ payer mix strategies.
An important factor in providers’ financial performance has been the
mix of commercially insured, Medicare, Medicaid, and uninsured patients.
Since the payments for commercially insured patients have been much
higher than for the others, many providers have systematically minimized
or avoided patients in the other three categories.  Even not-for-profit
safety net clinics have been forced to increase the proportion of commercially
insured patients to stay afloat financially.  Many providers have
also tried to hold down medical expenses, but it’s much harder to
do that.  (No one likes being yelled at by staff physicians and
nurses unions.)

In the PRW, the effectiveness of payer-mix
management strategies will be reduced.  Most people will have insurance
coverage, which will provide new revenue to providers who had been serving
the uninsured.  There probably will still be payment differences
between commercially insured vs. Medicare and Medicaid patients, but
the importance of payer-mix management will be reduced.  In response,
providers will need to focus more on managing their costs of delivering
care.  In other words, providers will need to move from payer-mix
management to cost management.

The second major change for providers
will be in provider payment formulas.  In the past, the fee-for-service
payment system rewarded a higher volume of services, regardless of the
patient’s health outcomes.  The CFOs of provider organizations
used key indicators such as the number of hospital admissions, the number
of medical procedures, and billable physician time.  There was
increased pressure for improved physician “productivity”, and billing
systems were upgraded to maximize fee-for-service revenue.

In the PRW there is likely to be a
movement away from fee-for-service payments — although it will probably
happen gradually — and the incentives for increased service volume
will be dampened.  Instead, providers will be paid for a “bundle”
of services, and there will be a greater emphasis on quality processes
and outcomes.  Hospitals will not be paid for a patient’s readmission
for the same medical condition or for correcting medical errors (“never
events”).  Physicians will be paid to take care of patients with
chronic conditions via a specialized capitation or case rate.
Providers will need to coordinate their services and improve the management
of chronic disease patients.  There will be stronger incentives
to invest in electronic health records, use evidence-based clinical
guidelines, and develop integrated delivery systems.  Providers
will need to move from increasing service volume to improving patient
care.

These are only a few of the changes
that will be driven by health reform; the effects of reform are likely
to be far-reaching.  The new legislative and market landscape will
be very different from the one that insurers and providers have been
accustomed to.  Smart health care organizations are already thinking
ahead and developing strategies to be successful. The ones that don’t
adapt will be moving against the tide.  Some insurers will gain,
and others will shrink.  Some providers will thrive, and others
will struggle.  Within a few short years, we’ll be able to sort
out the real winners from the losers.

Bill Kramer is an independent health
care consultant, focusing on health care management, finance and public
policy. Bill served as a senior executive with Kaiser Permanente for
over 20 years, most recently as Chief Financial Officer for Kaiser Permanente’s
Northwest Region. More information about Bill may be found at his website. You can read more of his commentaries
on health care management and policy at his blog, Now’s the Time, where this post first appeared.

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29 replies »

  1. What this website advocates is socialism. Socialism does not work, read history.
    No one has the right to healthcare. Based on what philosophy? If one want’s health insurance they can purchase it. If they cannot afford it then they do not have the right to force someone else to pay, that is called tyranny, stealing via the government.
    People need to think about what they are asking for. Obama is a politician! He has never worked a day in his life. To give politicians power over healthcare is dangerous, immoral, and illegal.

  2. The winners and the losers, who are they? was the question posed by our author Bill Kramer. I feel between the insurance companies, taxpayers, providers, hospitals, and patients involved in this current healthcare reform debate is like a boxing match. And let’s not forget the government’s control regarding the “public option” plan for universal healthcare to improve healthcare reform. This debate will not be resolved quickly. It will take a lot of time to put the pieces together to make this system better. As we already know, under Bill Clinton’s administration, he tried to resolve this problem for over 15 years and still could not come to a legitimate result. President Obama will not be able to do this either. It will take more time and compromise between all the parties mentioned above. I believe the patients should be the winners and not all the rest. But I also believe that people should also begin to take some responsibility for their own health care issues through preventive actions and living healthier lifestyles. How can one expect to the government or the insurance companies to keep footing the bill for people who continue to smoke, do not take part in regular exercise programs (walking, jogging or rehabilitation wellness centers), get plenty of sleep, keep regular checkups with their primary providers and screening exams and know what to do in case of emergent situations. Preventive healthcare I believe is the key to decreasing overall health expenditures. It may take a little more time from your practitioners, pharmacies, local communities to educate this information, but it could be worth it in the long run. You must always take part in your own healthcare and not rely on others to do so. Stay healthy and god bless. Michelle Mancell

  3. The overall winner in the PRW will and should be the American medical consumer-formerly known as patients. This is what real reform should be all about.
    My question is how did we stray so far from that basic goal in healthcare?
    Dr. Rick Lippin
    Southampton,Pa

  4. Insureds don’t submit out of network claims, almost 100% of the time even out of network doctors bill for payment. Doctors want paid so they want the insurance company sending the check strait to them not the member.
    “unless of course the complexity of forms submission makes it that way”
    You mean the UB and HCFA that most claims are billed on, I’ll bet you can’t find even one insurance company in the entire company that doesn’t accept those two forms. Do you think before you say this stuff?
    “need to hire outside claims processors along with the extra staff needed to pass paperwork to multiple insurance companies, as a strength of the system.”
    If you read you will notice Medicare and Medicaid billing are two of the most complex.
    Your one claim is indicative of the entire system while the studies done on millions of claims showing 95-99% are not denied is an outlier.
    I’m less concerned about how much trouble doctors have getting paid and more concerned about how much trouble Canadians have getting treated.
    Jerry,
    I own a couple Third Party Administrators (TPA) we process claims and administer various parts of benefit plans for employers and carriers. The work we do is done outside of carriers and with carriers. The carriers we work with have invested billions on research and education. We exploit those investments to the benefit of our clients. Under the present system there is a disconnect between small employers and the resources available. Carriers don’t have the staffing or the structure to push this to the employers and small employers don’t have the knowledge or resources to go and get it.
    The chance of you getting cancer is small and the cost great. The chance of anyone person having large claims in a given year is well less then 1 in 5. The cost ranges from minimal to substantial. People use to pay for 50% of their healthcare out of pocket and insurance only came into play when they had one of those years.
    Off the top of my head I think the chance of using your auto insurance is about the same as having large claims in a given year. I would have to research to be certain but fairly certain that is true.
    Benefits of increased pool size stop once a pool is actuarially significant. Benefits start to decrease at a certain size. Pools need to be competitive to be efficient, that is why universal unipools are not efficient, they might be cheaper but that is because they forcibly limit care by rationing. They don’t deliver their resources more efficiently. When you say your only going to spend $x your no longer insuring you are financing.
    “the bigger the pool of contributors, the more sound the funding for paying the beneficiaries.”
    But this large pool creates a ton of problems, it is considerably harder for a large fund to achieve sufficient returns then a moderate size fund. By their sheer size their investments move markets making it harder to manage risk, additionally numerous investments are to small for them to even invest in. A super large fund could deliver super safe returns, like what SS should have done, you wouldn’t want to invest all your retirement in it because they barely beat inflation, they can only invest in treasuries and similar investments.
    “Social Security, makes the most sense for paying for health care. The risk is spread out among every single tax payer/wage earner in the country.”
    SS is almost insolvent and already can’t deliver benefits promised. Not only is the return sub inflation but it can’t even deliver those. We already have two broke public plans, what good is a third?
    “It’s what virtually every other industrialized country already does.”
    If you do some research outside the liberal US media you will see all of these systems are also unsustainable. Do you really think we should replace one unsustainable system with another unsustainable system? Our systems are failing slower then theirs and most of our problems can be traced to Medicare and Medicaid. If you take away the poor results of those two systems we have the best healthcare hands down.
    Jim,
    There are some very successful provider/insurers. Here in Ohio Aultman only works with its own insurance company and a lot of people swear by it, they do a great job of keeping cost down. Problem is they are limited to one hospital. In CA the HMOs contract with PHOs and similar integrated networks that take risk, in addition to the Kaiser model. The biggest problem is like you said they need to be risk managers and generally speaking doctors are terrible businessmen. That should get a few comments.
    “when Nate and insurance companies talk about risk they are talking about cherry-picked risk.”
    Peter again being an idiot with no clue what he is talking about. Actually dumb ass, a large number of my new clients are the exact risk you claim I avoid. You see when someone has out of control risk or unmanaged risk their cost sky rocket. When cost sky rockets groups suddenly are willing to do the work required to manage it. That is when they are willing to work with me. Right now I am working on a 140 life company that wasn’t managing its risk and just got clobbered with a 60% increase to their fixed cost. Now we are talking about ways I can cut that increase back to what they were paying last year and implement programs to prevent it from happening again. Spin on that you intellectual clown.
    Jim,
    Without know who your insurer was, who the provider was, and seeing the actual claims there really isn’t anything that can be said. That is the problem with personal stories, you never have enough information to actually discuss the issue and it is such a small piece of the total picture. Large studies show very few claims are denied and those that are usually are a result of provider error.

  5. Jerry wrote
    “I’d guess that the risk of getting seriously ill or injured at some point in my life is much higher than the risk of my house burning down. It’s probably even a lead pipe cinch.”
    So much depends on your definition of “seriously” but it’s likely you’d be quite surprised to learn that your “cinch” is not so certain – better than the odds of your house burning down, but not a lock.
    The readily available data only hint at the probabilities, but for example, people 65+ # about 40 million, and account for about 13 million hospital stays annually. Some of those are multiple-visit stayers.
    The demographics of health care use should be more closely examined. It’s a class of factors that with careful study would yield better, & better-understood, solutions for reform.

  6. Nate,
    My personal experience with insurers is similar to Barak Obama’s mother. When she was dying of cancer, they were fighting her over their liability for her care.
    I suffered an injury that required me to have daily treatments and make weekly insurance claims. My claims were initially denied (for duplicate biling) every week. I had to plan to spend 2-4 hours every week while at work to get the insurer to pay. This lasted for six months.
    I was recently on COBRA. I was paying $900 per month, but paying the bill was not enough. They would cash the check, but never bother to activate my coverage. I was required to call my COBRA provider every month after I paid to activate my coverage. If I didn’t call, every claim I made for my monthly medicatons was denied.
    I can easily cite 10 other personal examples of the the insurer denying an initial claim before paying. In my personal experience, insurers search for any reason to deny a claim. My Non-medicine related claims have had the initial claim denied more than 50% of the time. When those claims are denied it will take 90 days or more to have the claim paid 90% of the time.

  7. Jerry, when Nate and insurance companies talk about risk they are talking about cherry-picked risk. When the risk is too high they simply off load it to government (Medicare), the un-insured (creating more of them) , the under-insured (more of them too), pre-existing (don’t really want the business) and high decutible plans. Insurance is not healthcare and “reforming” insurance will not reform healthcare. You are right that a larger pool divides the costs and expenses, that’s why universal single-pay is the best system if you want to control and spread costs – one big pool.

  8. Jerry,
    You ask what value do insurance companies bring to the process.
    Their most important role is to manage risk for the general public. In theory, their is universal access to health care and everyone is covered for any medical condition. Insurance companies spread the cost of taking care of a few by having everyone make monthly payments.
    The goal of health care reform is to come closer to achieving the above ideal.
    Another key role of insurance is to design health care products that give different levels of access to the system. Consumers of insurance pay a monthly insurance premium to access the health care system, i.e., fee-for-access. Insurers manage the flow of money through the health system.
    fee-for-access -> insurer -> fee-for-service
    The way it is described here in a reformed system it should more like:
    fee-for-access -> insurer -> bundled payments
    In a truly reformed system the flow would be:
    fee-for-access -> insurer -> fee-for-access
    If Service providers wanted to become insurance brokers, they could market and sell their own health care packages that look like todays insurance products. You could eliminate the middle man (insurers), but service providers would be forced to learn how to manage risk.
    fee-for-access -> insurance broker (i.e., health care provider)-> fee-for-access

  9. Thanks, Nate.
    I’m still not clear on your assertion that “The (insurance) Industry does a great job of education.”
    You described some activities associated with your own practice and customers (how do you describe your job? are you a broker? salesperson? customer service rep? some other role?), so it sounds like you believe that you do a “great job of education.”
    But that seems like an entirely different thing to me.
    As for your comment about transferring risk – I’m not sure how that model applies to health care. The risk of my house burning down seems pretty remote, but the cost to fix or replace it would be huge. I obviously carry homeowners’ insurance against that risk.
    But I think health care is different. I’d guess that the risk of getting seriously ill or injured at some point in my life is much higher than the risk of my house burning down. It’s probably even a lead pipe cinch.
    I understand that one of the key principles of insurance is spreading the risk around as much as possible. The bigger the pool, the better, right?
    I know the same is true of pensions – the bigger the pool of contributors, the more sound the funding for paying the beneficiaries.
    It seems to me that the same model used for the biggest pension of them all, Social Security, makes the most sense for paying for health care. The risk is spread out among every single tax payer/wage earner in the country.
    It’s what virtually every other industrialized country already does.
    That sounds like it would be a no-brainer here.
    To me, anyway.

  10. Nate, I didn’t assert any percentage on denials, I only said that insurance companies can just deny the claim and let the provider/insured struggle with the paperwork to get paid. Obviously I don’t consider when the claim was submitted as an insurance problem, unless of course the complexity of forms submission makes it that way. But you seem to hold that all the efforts taken to process claims, including the need to hire outside claims processors along with the extra staff needed to pass paperwork to multiple insurance companies, as a strength of the system. First pass payment rates may or may not be typical of how long a claim takes to be processed, depending on the type of claim, but 5-10% denial rate can be a huge # of claims when you look at the number processed. And I wonder what the payment rate is for insureds submitting claims from out-of-network providers where the insured submits the claim. But clearly all the money spent just to process “clean” claims to the insurance companies takes money away from healthcare. In my own experience with BCBS they just kept either loosing paperwork or refused to process for a legitmate claim of about $1500 – it took me 6 months and a few letters to the Commissioner of Insurance. They never offered to help me get the claim paid, they just didn’t issue payment – that’s cheap on their part. Were they trying to teach me a lesson about using out-of-netowrk? I attempted to Goggle some info on how much trouble Canadian docs have in getting their claims paid and couldn’t come up with anything – maybe because it’s not an issue there.
    http://www.medicalnewstoday.com/articles/8800.php
    http://economix.blogs.nytimes.com/2009/01/23/how-do-hospitals-get-paid-a-primer/?apage=5

  11. And when there are denial most of the time it is the doctors office fault. There is an entire industry that helps doctors clean up their billing becuase some suck that bad at it.
    http://www.physicianspractice.com/index/fuseaction/articles.supplementDetails/articleID/1242.htm
    “For example, the St. Louis consulting firm LarsonAllen surveyed 23 practices that submitted accurate claims to their clearinghouse 99 percent of the time. Those practices had average days in A/R of 40 and a net collection ratio of 97 percent. They posted bills within a day and payments within two days, and they worked denials within 48 hours. They had processes in place to understand why claims were denied and to take corrective action.”
    Can you read that Peter? Accurate claims result in 97% payment. You have made this stupid statement numerous times and been corrected every time, how much proof do you need to finally sink in your full of it?
    Know what does result in denied claims? Poor billing;
    “When practices come to Med3000, Schickele notes, their claims denial rates are typically above 10 percent. The RCM firm, which receives a percentage of collections, works with practices to get the denial rate below 5 percent, “because that’s our margin. If we can’t get these claims going clean, it’s never going to work for us. And the client will also be unhappy, because we have to keep calling their office to fix the claims. So both sides are incentivized to get those denials down.”
    Again this is what the billers hired by the physicians claim get processed;
    “MedSynergies and athenahealth say their average first-pass payment rates are 95 percent. MED3000’s average rate exceeds 90 percent.”
    Where are the denial Peter?

  12. While most claims are processed within a relatively short period of time after their receipt (only 6 percent
    of claims take more than 30 days), almost 30 percent of claims are received more than 30 days after the date on which services were provided to the patient, with 16 percent received after more than 60 days. The length of time taken by a hospital or a physician’s office to submit a claim obviously has an important bearing
    on how long it will take to receive payment for the services in question. Additionally, lack of information on the claim is still the number one reason for pending claims, and the filing of duplicate claims by hospitals and physicians’ offices is the predominant reason for claims denial. The promptness and thoroughness of claims submission, and the frequency of duplicate
    claims, are all matters largely within the control of health care providers.

  13. lets once again point out how much of an idiot peter is, between 95 and 99% of all claims are paid within 30 days. Please idiot in chief tell us how questioning 1% of claims is making insureds jump through hoops.
    everyone point and laugh at the moron and one day he will hopefully learn.

  14. “Everything gets paid initially, there is no auditing done on the front end, its all automated.”
    Insurance companies have a very inexpensive way to manage errors, they simply deny the claim and let the insured jump through hoops and paperwork to get paid. See what an outcry there would be if Medicare did that.

  15. Jerry,
    When you transfer risk you pay a portion of the potential liability to relieve your self of that liability. An example of this would be unless you are a terrible driver your auto insurance cost a fraction of what it would cost to repair the car. This is becuause you pay based on the likelyhood of needing to repair a care.
    Financing care is paying for something you know is going to happen, like filling the gas tank or replacing air filters.
    You know you need to fill your tank next week and you know it is going to cost $30. To fill your tank will cost you $30. To pay an insurance premium for your insurance company to pay to fill your tank will cost you $36. There is no risk here, you know you need to fill your tank so there is no reason to pay someone 36 to take the risk of you needing a 30 tank of gas.
    Routine medicine, annual check up, trips to the doctor for colds are all services that should no be insured.
    Insurance works great to protect against accidents. It works great to protect against illness like cancer as long as you buy it before you get cancer or seriously sick. To many people tried and still try to not buy insurance until they need it. That gaming of the system is what lead to pre-ex rules and canceling policies when people lie. Life insurance, Aflac, disability insurance, all of these work great and health insurance use to work just as well.
    Better ways to take care of yourself. Treatment alternatives. Ways to save money. I spend a considerable amount of time with my clients showing their employees way to save money and live healthier. We are always doing newsletters and flyers. Right now we are educating employees about shopping pharmacies. Some will charge you your full co-pay even if the drug cost less. Even though it doesn’t save my clients money, the full cost is paid by the co-pay, we go through the Rx bills each month and look for people that can save money by going to a different drug store. Insurance companies have free nurse lines and access to websites where members can learn more.
    Besides all the CBO, CMS, GAO studies showing the horrendous error rates of government plans my company processed medicare supplement claims for over 10 years and saw first hand how bad of a job they do. Everything gets paid initially, there is no auditing done on the front end, its all automated.

  16. “They aren’t suppose to add value to the financing of health care service they are suppose to add value to the tranfer of risk,”
    Yes, transfering risk from insurance companies to premium payers/patients/government and the collections department of providers so that they make profits, dole out bonuses and investors make a return. Like Jerry said, “What value do insurance companies bring?”

  17. Hi, Nate.
    Thanks for your response. A coupla questions –
    What’s the difference between “financing health care services” and “transferring risk?”
    Maybe I misused the term, because what I was referring to was actually paying for the individual patient bill, and not financing in the sense of providing loans or investment.
    And, since I think you mean ‘transferring risk’ in the same sense that it’s applied to other areas of insurance (against the risk of fire, casualty, accidents, etc), is that model even appropriate when it comes to health care services?
    Also, what do you mean by “The (insurance) Industry does a great job of education.” Educating who? About what? Examples?
    Finally, do you have any evidence to support the statement, They process claims and prevent fraud far better then the government ever has.?
    Thx, J

  18. The government wins. Old people will die quicker. Insurance co and hospital execs will give more campaign contributions.
    Doctors will become window washers.

  19. Jerry,
    They aren’t suppose to add value to the financing of health care service they are suppose to add value to the tranfer of risk, something they do really well when allowed to. The Industry does a great job of education. They process claims and prevent fraud far better then the government ever has.

  20. I am in complete agreement with “watchdog, md”‘s post above re. doctors vs. hospitals. Although they are both providers, that’s as far as it goes; they are far from being the same entities and should in no way be lumped together in any serious treatment of this topic.

  21. Can someone please answer what I believe is a simple question – what value do insurance companies actually add to the process of financing health care services?
    Ideally, every player needs to bring something of value to the table, or they don’t get to play. What value do insurance companies bring?
    Thx

  22. As you state above, the movement towards cost management and improving patient care must be at the center of health reform, and the ability of doctors and payers to work within these new paradigms will determine their success. However, I worry that the bills currently in review aren’t doing enough to truly reduce costs and improve care. We need better incentives for coordinating care and offering home health services – through the use of telehealth and home care, for example. But I am fearful that the health reform bills are going the wrong direction in terms of home based care… many of the bills are actually proposing cuts in reimbursement for home based services, making those businesses almost impossible to maintain.

  23. HIT vendors will make out the best.
    After all, they produce inferior and insufficient products but that does not matter.
    They have infiltrated the White House, gaining inside backing from health reform czar(ette) N. DeParle (recent former Cerner Board member)and Allscripts CEO Tullman (Big O advisor).

  24. 1. “…Insurance reform: guaranteed issue (no medical screening), along with rating rules and standardized benefits in the individual and small group markets.”
    STANDARDIZED is the key word there. If the reform allows for high-deductible, low-premium catastrophic insurance plans for the young, healthy and irresponsible, risk management and adverse selection will still exist, though on a smaller scale.
    2. “…Cost containment: increased attention to costs, transparency and accountability for insurers and providers.”
    That would be a real challenge to get hospitals, clinics and practices to disclose prices they charge private insurers and “self-pay” patients.
    3. “…Payment reform: a gradual shift from fee-for-service to bundled payments, as well as incentives for quality outcomes.”
    This can be tricky too, because there are quite a few moving parts. Patients can (and usually do) have multiple conditions. They may not follow the recommended treatment, especially, in ambulatory settings, etc. I am all for switching from the fee-for-service reimbursement model to whichever makes sense; we just need to figure out how to quantify outcomes.
    4. “…Emphasis on prevention, primary care, chronic disease management, and the use of comparative effectiveness research.”
    I would add end-of-life care to the list.

  25. Mr. Kramer shows his disdain for doctors by lumping them with hospitals and referring to them as “providers”. Mr. Kramer, shame on you!

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