Health for life

Lets choose the health insurance channel!

A running joke among many managed care medical directors is that the typical enrollee spends hours comparing features and prices for their flat screen TVs and minutes selecting their health insurance.  Far too often, its after enrollees get sick that they discover that many of their assumptions arent meeting the reality of the provider network, coverage exclusions and out-of-pocket expenses that they chose. 

Whats more, juicy anecdotes of failed enrollee expectations (such as unproven cancer treatments in cute bald children) have fueled advocates demands for a generous version of orm (such as a single payer with a rich one-size-fits-all benefit design).

Thats why the Disease Management Care Blog found this Kaiser Health News report interesting.  It raises two issues.

1. The Merits of Consumer Shopping.

According to the KHN report, what were reading elsewhere isnt quite true because users of Massachesetts health insurance exchange (HIE) are being flummoxed by a thicket of multiple insurance options with premiums that vary according to provider tiers (some hospitals will cost you more), out of pocket expenses (a.k.a "skin in the game" stuff like co-pays and co-insurance) and exclusions (some things are not covered).  As a result, a shopper can expect to spend "six to eight hours" selecting a plan!

The DMCB is shocked, shocked by the specter of consumers having to spend as much time comparison-shopping for health insurance as the typical amount of time used checking out Consumer Reports, scanning the newspapers for sales, seeing if Amazon has a better deal and driving to several electronics stores for that best flat screen, Blu-Ray player or speaker system.  Dammit, says the DMCB, buying health insurance is important and it deserves that much time.  If an HIE forces consumers to finally pay attention, the DMCB says that is a good thing.

As an aside, the DMCB also points out that the art and science of HIEs are still evolving.  With better informatics and user-friendly on-screen interfaces, it should get better.  Given governments heavy hand, however, the DMCB predicts HIEs will never match the astonishing slickness of parallel on-line consumer purchasing aids, such as smart iPhone apps.  Taxpayer consumer expectations will continue to not be exceeded.  They will be eventually met, however.

That being said, however, the Massachusetts experience also speaks to the naive assumptions underlying the Affordable Care Acts HIE provisions.  If that remains problematic, consumers will always have the option of letting D.C.s Pete Stark, Max Baucus and Kathleen Sebelius save them time by arranging the details of their insurance for them.

2. Anecdotes and Framing

The underlying tone of the KHN piece vaguely suggests that consumerism and health insurance is a bad thing.  From the typical use of a selected negative anecdote, the skeptical visage of the person featured in the article, a "I could not figure it out" sub-headline, the sub-text portrayal of insurers as being intentionally opaque and the prominence given to saving money all paint a picture of a system that is failing. 

Good grief, HIEs have just gotten out of the crib and KHNs reporting suggests that the liberal and progressives still want to strangle this toddler.  Once again, the DMCB is shocked... shocked.

One of the stories behind the story of Affordable Care Acts successful passage and survival to date has been the silence of the commercial insurers. Its not a good political or technical sign for the health insurance exchanges when Aetnas CEO goes public like this.....

While the Governors Mansion in Pennsylvania is currently under the control of the Republicans, the Disease Management Care Blog knows the states Insurance Department is relatively apolitical. Thats why this September statement by Pennsylvania Commissioner Consedine before the U.S. House Ways and Means Subcommittee on Health is quite telling. 

In it, Mr. Consedine describes how the Keystone state is encountering difficulties implementing an health insurance exchange. As DMCB readers will recall, exchanges are a key feature of the Affordable Care Act, because theyll provide an online market that will enable individuals to obtain coverage.

According to Mr Consedine, CMS is failing to support a good law with the many regulatory details that turn a vague idea into a functioning reality. These failings include:

1. "Interim," not "final" rules on eligibility, tax credit calculations, cost sharing and the role of brokers

2. Little formal guidance on the determination of the essential health benefit.

3. Delays in issuance of regulations on how states and Uncle Sam will split or mutually indemnify the myriad costs of the exchange and the Federal Data Hub.

4. Delays in the issuance of regulations on how states can exit a federally run exchange to set up one of their own.

5. Lack of clarification of CMS impact on insurance markets operating outside the exchanges.

6. Little understanding of whos in charge of consumer protection statutes.

7. Confusion over reconciliation of multiple states insurance laws and regulations in multi-state exchanges.

8. No guidance on how to roll long-extablished and well functioning state-subsidized insurance programs into the exchanges.

9. Concern that funding of the information technology could be clawed back if Medicaid eligibility does not meet CMS criteria.

10. Little guidance on whether exchanges will need to provide consumers with a list of providers who are accepting new patients.

The concerns are also damning in the context of the the normal tug of war between the states and Washington DC. Thats because in his testimony, Mr. Consedine states he wrote to HHS weeks ago and has not received a reply.  While its not unusual for the Feds to stiff politically inconvenient inquiries, the Disease Management Care Blog is fearful that the reason why HHS seems unwilling to provide a timely reply is because it doesnt know the answers.

If Pennsylvanias experience is typical, that means the roll out of the exchanges could be significantly delayed.

You read it here first.

9/26/12 Update: Senator Hatch agrees with the DMCB