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Tag: Fraud

Good Business Models and Bad Business Models.

You may have received a refund check in the past few months from your health insurer. This is not your individual reward for staying healthy; it is your insurer’s punishment for making too much money because you did.

Obamacare includes what the health care technocracy calls the “MLR rule” – minimum requirements for medical-loss ratios – or the percentage of premiums collected by health insurers that must be spent on medical care or refunded. The inverse of the MLR is the percentage spent on administration and marketing, and earned as profit. Obamacare sets minimum MLRs of 80 percent for individual and small group plans, and 85 percent for large groups.

Aside from its obvious populist appeal, this profit regulation mechanism signifies a belief, now enshrined in legislation, that health insurance markets do not work. Without such a rule, the architects of Obamacare believe, insurers can name their prices, however inflated, and we all just pay.

In the short term, that is true. Most health insurance plans price only once per year, are subject to long delays in cost trending information and multi-year underwriting cycles, and endure the meddling of a carnival midway’s worth of employee benefits tinkerers, agents, brokers, consultants, and other conflicted middlemen. But in the long term, over multiple annual cycles, premiums do rise and fall, and the health insurance industry’s fortunes with them.

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The Promise of Electronic Healthcare Records

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should frustrated that he was never confirmed.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

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