Almost a hundred years ago famed reporter/muckraker
Lincoln Stephens famously proclaimed, “I have seen the future, and it
works.” Of course, he was talking about
the Soviet Union and time proved that he couldn’t have been more wrong. I hope I don’t prove equally wrong when I say
that our health care future lies in exchanges.
I should note upfront that my prediction may not
mean what most readers probably think it does.
I’ve written about exchanges several times in the
past (e.g., the
botched rollout of healthcare.gov, the
rise of private exchanges, and – two years ago – questioning
the resistance to the concept) but what triggered me
again was a reference I saw recently that roughly one
in two new Medicare beneficiaries enroll in Medicare
Advantage (MA) plans. It seems to be an
accepted truism that baby boomers like MA, so as more of them become eligible
for Medicare, MA grows. Almost 30% of
all Medicare beneficiaries are now in MA.
So we’ve got the Medicare population where enrollees
are able to go online to view their choices of health coverage, compare
coverage and premiums, and enroll. It sure
sounds like an exchange to me.
Of course, for the pre-Medicare population not
covered by employer coverage, we’ve got the much ballyhooed state and federal
exchanges established under ACA. They
are starting to pick up steam; despite issues at both levels, exchange enrollment
is now around 55% of projections, according to recent
analysis from Avalere.
Finally, we have employers rushing to private
exchanges: Aon
Hewitt research sees 33% of employers moving to a
private exchange in the next 3-5 years. No
wonder many of the big benefits consulting firms, like Aon,
Mercer
or Towers
Watson, plus some of the larger health plans (e.g., Wellpoint),
have established, bought, or partnered with private exchange vendors. It has become a favorite way for employers to
lock in costs for retiree
health obligations, and increasingly for active employees as well, both
using “defined contribution” approaches.
The landscape looks like exchanges all around,
even though that doesn’t mean everyone actually have many choices. For example, The Wall Street Journal found
515 counties, in 15 states, where consumers getting coverage through the
federal exchanges only had one choice of a health plan, out of the counties it
looked at in 36 states. The New York
Times reached similar conclusions in its analysis
last fall. Medicaid recipients often lack
options as well.
Surprisingly, employers aren’t much better. According to the Kaiser
Family Foundation annual survey, 87% of firms offering
health coverage only offer one plan type (e.g., PPO versus HMO or HDHP). Choices within that plan type rarely even
involve multiple carriers.
Consumers say they want choice. EBRI
found that that only 35% of those with employer coverage wanted to continue
having employers make the choices of health plans. 45% wanted an exchange-type approach -- where
they got to pick their coverage, their employer made a fixed contribution, and
they paid anything about that limit – and 21% wanted the money from their
employer to either spend on health insurance or keep, as they saw fit. In terms of health plan choice, 26% were
extremely interested in more choices, with another 37% very interested.
EBRI noted that most employees were only somewhat
confident of their ability to use objective ratings systems to make their
choices, but I thought it was equally important that employees’ confidence that
they could pick the best plan for themselves was virtually the same as their
confidence that their employer picked the best plan for them.
Having all these different exchanges for health
choices makes no sense. It’s crazy that
people’s health plan choices vary so widely based on current economic status
(e.g., Medicaid or not), not only employment status but also size and choice of
their employer, age/eligibility for Medicare, and geography,
to name a few factors. The commercial
market and the public coverage don’t typically even use the same types of
network plans: Medicaid and Medicare tend to use HMOs, while exchange plans
tend to be PPOs (although often ones with narrow
networks).
I’ve complained about this before (Medicaid Is Different…Isn’t It?),
but the very real prospect of someone having to cycle through very different
application processes, coverage options, number and type of choices, provider
networks, and sources of funding as they go through common life changes is just
ridiculous. It’s administratively
expensive, confusing for everyone involved, and hell on continuity of care.
In a more perfect world, one in which there had been
the possibility of bipartisan agreement and some prospect of a rational
approach to solving problems, ACA could have established exchanges that would offer
coverage that applied to everyone. No
hidden subsidies for higher income individuals, as is true for Medicare and for
employer-provided coverage. No archaic or
(literally) parochial benefit designs. Consumers
wouldn’t have to switch their coverage just because they gained or lost a job,
or turned 65. Instead of that kind of
sweeping simplification, we’ve just created another kind of balkanization in
our health care system.
If nothing else, though, the exchanges may help prep
consumers for radically different ways of obtaining their health plan. A recent global
survey by Accenture found that two-thirds of consumers would
be willing to buy insurance from organizations other than insurers; 23% were
interesting in purchasing from online companies like Amazon or Google, which
has created some
waves in the insurance world. The study wasn’t focused on health insurance
but the lessons sure seem applicable, and health plans should be worried.
I like consumers having a choice of health plans,
offered on a uniform platform that facilitates comparison shopping, but exchanges
for health plans are only a first step.
What I’d like to see are exchanges for provider services.
I hate that a provider’s cost for a given consumer
is dictated by whatever health plan a he/she happens to end up in, and that the
best providers for a given condition may not even be part of their health
plan’s network.
Yes, most people would agree that we have a problem
with transparency of cost & quality in health care, and, yes, there is a
lot of work being done on the problem (see Does Anyone Really Know What Price
It Is?), but exposing health
plan-negotiated prices is not enough. The
underlying problem is that using health plans to price providers’ services just
makes the whole process way too opaque.
We need to get to the point where providers’
services themselves are openly offered in a competitive market.
Imagine being able to shop for, say, heart
transplants or colon cancer care through an Amazon-like marketplace, with a
wide range of providers offering the service, pre-set prices, full “product”
descriptions, and plenty of reviews from previous patients. If you think that sounds far-fetched, well,
you can go on the Internet now and quickly gets lots of prices for laser eye
surgery or concierge medicine. It’s
funny how lack of insurance coverage for their services “helps” providers
advertise their costs.
Granted, people aren’t going to shop for the best
provider when they are having a heart attack or their appendix has burst, but
using those kinds of emergency examples as an excuse not to try to move to a
world where we facilitate consumers directly shopping for the best providers in
other situations is cutting our noses off to spice our face (and I wonder how
much that would cost!).
Going to such a marketplace/exchange approach would
require a very different competitive mind-set from providers, which many would
hate but in which I think some of the best providers could do very well,
especially if it meant less interference from health plans. And, of course, it would mean a very
different, less paternalistic role for health plans, an example of which I’ve previously
proposed.
To paraphrase an old spiritual, let our people
go! Let them shop for their health care
openly, not just their health plans.
Good piece, Kim. I agree "we need to get to the point where providers’ services themselves are openly offered in a competitive market." Besides more competition (i.e. an Amazon-like marketplace), to keep health plans "honest" I think the ACA should have included a public option for consumers. This would have driven down premiums significantly.
ReplyDeleteGood article. I have a question about ACA. Coverage is mandatory. What happens if someone chooses not to enroll and pays the penalty but then needs to be hospitalized? Is the hospital forced to treat them as has been the case in the past? Or can they turn them away? Do you happen to know?
ReplyDelete@Brevard Animal Rec Club - yes, I believe hospitals still have to treat, but the federal funds that used to help subsidize such uninsured are much reduced under ACA, so hospitals are very worried about people opting to pay the (small) fine instead of getting coverage.
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