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Understanding Health Insurance Understanding Health Insurance A Guide for Brokers, Administrators, Students and Healthcare Practitioners 1 2 Understanding Health Insurance A Guide for Brokers, Administrators, Students and Healthcare Practitioners Copyright © 2010 by Gary Fradin All rights reserved. This book may not be duplicated in any way, either in books, digital form, or any other medium, without the expressed written consent of Gary Fradin, except in the form of brief excerpts or quotations for the purposes of review ISBN: 978-0-557-42092-6 3 4 The Author Gary Fradin teaches healthcare economics to insurance brokers and healthcare professionals nationally. He is President of HealthInsuranceCE LLC, which provides health insurance continuing education courses to licensed insurance brokers nationally. He has authored 2 previous books, Healthcare Problems and Solutions in 2008 and Moral Hazard in American Healthcare in 2007. He also has had numerous articles published in industry journals. Gary holds Masters degrees from both Harvard and London Universities, and a Bachelors degree from Lancaster University in England. He is a licensed health insurance broker and lives in Massachusetts. 5 6 Preface This book grew out of discussions I had with many health insurance brokers between 2007 and 2009. I had been lecturing regularly to groups of experienced brokers. They typically understood their businesses well – underwriting, policy provisions and regulations. Their questions and comments typically reflected a high degree of policy knowledge and professionalism. But I was struck by their lack of understanding about the context within which they worked. Though they knew a great deal about specific policies, they frequently knew very little about policy implications or the overall working of our health insurance system. They tended to see our health insurance system from a very parochial perspective. Brokers, typically, take few courses in health insurance economics or policy analysis. Yet their clients viewed them as having great expertise about the workings of our healthcare system. Their clients, and often the brokers themselves, equated knowledge about policies and regulations with knowledge about our health insurance system. These are, in my opinion, different fields of expertise. I wrote this book to address this disparity. I describe various forms of health insurance – Consumer Driven, Managed Care, Single Payer, Medicare and others – and show how they function economically and systemically. Hopefully health insurance brokers can use this book to complement their regulatory knowledge and policy expertise. Hopefully also, it will help them provide better advice to their clients. *************** Parts of this book have previously appeared in Health Insurance Underwriter, a publication of the National Association of Health Underwriters, and as courses offered by HealthInsuranceCE. Both have graciously granted permission for reproduction here. 7 8 Table of Contents Introduction: We Spend Too Much on Health Insurance Page 11 Part 1: The Cost Problem and Our Options Page 15 Chapter 1: The Cost Problem Page 17 Chapter 2: Some Background Page 25 Chapter 3: Our Options Page 41 Summary and Review Questions Page 51 Part 2: Understanding Employer Based Health Insurance Page 57 Chapter 4: History and Development of ER Based Insurance Page 59 Chapter 5: Goals and Incentives with ER Based Insurance Page 75 Chapter 6: Problems with ER Based Insurance Page 85 Chapter 7: An Alternative: The VA Healthcare System Page 103 Summary and Review Questions Page 115 Part 3: Our Health Insurance System Page 121 Chapter 8: Fee for Service Financing Page 123 Chapter 9: A Word About Medicare Page 171 Summary and Review Questions Page 189 Part 4: Insurance Forms and Reforms Page 195 Chapter 10: Health Insurance Forms Page 197 Chapter 11: What Proponents Say About Each Other Page 209 Chapter 12: A Brief History of Health Insurance Reforms Page 221 Chapter 13: Why Reforms Fail to Control Costs Page 237 Summary and Review Questions Page 251 Part 5: Expanding the Supply and Improving Efficiency Page 257 Chapter 14: Expanding the Supply Page 259 Chapter 15: Allocating Resources by QALY Page 283 Summary and Review Questions Page 309 Part 6: The Broker’s Role Page 315 Chapter 16: What Responsibilities Does the Broker Have? Page 317 Chapter 17: Excess Treatment Costs and Harms Page 335 Chapter 18: Are Teaching Hospitals Always Best? Page 343 Conclusion: How Should a Broker Proceed? Page 353 Summary and Review Questions Page 357 9 10 Introduction This book describes our health insurance system with the aim of understanding why we spend so much on healthcare and what alternatives we have. It also explains why excessive healthcare spending is bad both for our economy and for our health. In brief: Excessive healthcare spending deprives us of resources to invest in education, public transportation, environmental protection, new plants and equipment and other things vital to our economic health; Excessive medical spending can crowd out true health investments. Good health relies largely on good lifestyles, including appropriate nutrition, exercise, job satisfaction and similar components. Medicine can only correct unhealthy lifestyles to a point. We need to invest in health, not just medicine. Too much medical spending is bad for us. We have alternatives. Will we embrace them? Three Potential Healthcare Spending Futures As I wrote this book, I considered that our healthcare spending trends can go in three possible directions in the future. First, we can reform healthcare to make our system more efficient. I’m not terribly optimistic about this. We’ve tried to reform healthcare for years, but have never been able to rein in spending – this despite the best efforts of Presidents Nixon, Carter, Clinton, W. Bush and now Obama, plus myriad other state and federal cost control programs. Each meaningful spending control reform generates such vicious opposition that it ultimately fails. Evidence of our historic cost control failures showed up in the 2009 healthcare inflation rate. Spending grew by 1% of GDP in 2009, the largest 1 year increase since 1960. The historic record is one reason why I’m pessimistic about our ability to reform our way to meaningful healthcare cost efficiencies. I’m also pessimistic about efficiency improvements via reforms because we face a fundamental structural problem in our healthcare financing system, one rarely discussed in the popular literature. The problem: most of our healthcare spending goes to people with chronic medical problems – problems that last for many years. Yet we finance medical care with 1 year long, renewable health 11 insurance policies. Subscribers renew policies based largely on price. This puts extraordinary pressure on carriers and providers to maintain a short term cost control focus. Effective chronic disease management, however, requires a long term focus for best results. Our short term policies incent carriers and providers the wrong way. This disconnect leads to higher than necessary long term costs. We cut, for example, funding for podiatric visits by diabetics with no foot ailments, and then generate the highest foot amputation rates among developed countries. This situation plays out daily in our medical protocols with many different disease types. Though healthcare system reform is a laudable goal, I don’t see it leading to meaningful cost controls. Second, we can continue to adjust to high healthcare inflation. I think this is probably our most likely scenario, as this is what we’ve done in the past. Every year, a little more of our budget goes to healthcare. This is unhealthy for the reasons stated above. In addition to those reasons, I worry about something else in this scenario. I worry that there is a tipping point – a point at which we simply cannot continue spending a greater percent of our budget on healthcare every year. I worry that when we reach this tipping point, we’ll react with a series of bad healthcare spending decisions that result in more harm than necessary to us. That raises the third potential healthcare spending future. We could cut healthcare spending, perhaps voluntarily (admittedly not likely) or under pressure from some future event or situation…a war, a recession, some natural calamity or even the normal business cycle. Thus, I see three different potential futures: We could control healthcare spending through reforms, which I don’t think will happen; We could allow healthcare spending to consume a larger and larger amount of our economy, which I think will probably happen; and/or We could hit a tipping point, with unforeseen and unknowable implications, which I fear might happen. Gradual Trends vs. A Shock As I consider these three alternative futures, I remember a story former Vice President Al Gore told frequently about global warming during the 2000 12 election campaign. It’s the story of the frog in a pot of water, and I think it applies to healthcare spending: 1 If you put a frog into a pot of cold water, he swims around happily. Then, if you very slowly raise the water temperature, the frog continues to swim, though slightly less energetically and happily over time, until the water temperature ultimately gets high enough to kill him. Alternatively, if you put a frog into a pot of hot water, he will immediately jump right out. (I don’t advocate killing frogs and neither, to the best of my knowledge, did Gore.) We may adjust ourselves to healthcare spending increases – like the first frog – and learn to live with them for awhile, so long as the annual increments are tolerable. We may not notice the heat rise so much, provided it doesn’t rise too much at any one time. A Boiling Pot What happens if – instead of premiums rising slowly (slowly?) over time - we get hit with a sudden wallop? Let’s hypothesize a potential and uncomfortable future. Let’s say our current healthcare reforms fail to control costs, which continue to rise faster than GDP.
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