Tag: Insurance

Buying Insurance

We Don’t Buy Insurance for Ourselves

Posted on by jabittan
Why do we buy insurance of any kind? Is it really for ourselves and our own benefit, or is there something else going on with insurance decisions? According to Venture Capitalist Chris Brookfield, as quoted in Dave Chase’s book The Opioid Crisis Wake-Up Call, there is something beyond our own self interest at play when we decide to buy insurance.

 

Brookfield is quoted as writing, “Persuading individuals to buy insurance is kind of backwards. I saw this in India all the time. Individuals do not value their own risks – their relatives and neighbors do.” 

 

Buying insurance is actually more about our loved ones and our responsibility to our community than it is about ourselves. It is about protecting the financial standing of our relatives and those who would help us if we were down as much as it is about protecting our own financial standing. The standard story tells us that insurance shifts risk from ourselves to a group of individuals, but as Brookfield continues in the book, it really shifts risks from our immediate known allies, into a broader group of people that we don’t necessarily know.

 

If I don’t have health insurance or auto insurance and die in a terrible car crash, I am not the one who will bear the costs of the accident. My loved ones and other people in the community involved with the crash (other drivers or the owners of any private property that was damaged) are the ones who will face the costs. On their own it would be hard to manage the costs, but pooled together, the costs and the risk could be shared. In a situation where my death occurs, it is other people who derive the value of the insurance.

 

I’m sure there are some insurance products that are pretty solidly just about the individual buying the isurance, but it doesn’t seem to always be that way. Buying insurance seems to be an act of signaling, as Robin Hanson discusses in his book The Elephant in the Brain. Buying insurance isn’t all about sharing risk, it is also about showing others how much you care about them and about showing the community how responsible you are.
Self-Insured Health Plans

Self-Insured Health Plans

Posted on by jabittan
“A self-insured health plan,” writes Dave Chase in The Opioid Crisis Wake-Up Call, “is established when an employer sets aside some of its funds to pay for employees’ medical expenses. Employees then contribute to the plan rather than pay traditional premiums.”

 

In the United States, it is not uncommon for large employers to chose to be self-insured rather than to offer health insurance provided directly through an insurance carrier such as Cigna or Anthem. Chase explains that self-insured plans shift risk from the insurance carrier to the employer, with the benefit of reduced administrative costs and changed financial incentives. Large carriers are often still contracted with in a self-insured system for some administration and bill paying functions. In a traditional relationship, as Chase explains, employees pay premiums and “if the premiums exceed the medical expenses, the carrier wins.” Self-insuring eliminates this aspect of health insurance, reducing the total amount that employees should need to contribute by eliminating a profit motive for the carrier.

 

Chase highlights another benefit of choosing to self-insure, lower taxes and fewer regulations to abide by. In the United States, each state has an insurance commission that sets its own standards and requirements for insurance (auto, home, medical, etc…). The benefit according to Chase is that, “the Employee Retirement Income Security Act of 1974 [ERISA] states that a private, self-insured health plan is administered in accordance with its [ERISA’s] terms and federal rules. So, these plans aren’t subject to conflicting state health insurance regulations or benefit mandates.”

 

This is an important point that I have been thinking about in Nevada. My state requires that health insurance cover ABA treatment for children with Autism until they turn 21. However, not all of the plans that Nevadan’s have through their employers actually cover ABA treatment and some only cover ABA treatment until a child is 7 years old. While selling insurance across state lines (as in buying an insurance plan sold in California and according to California statutes and regulations) is not legal, offering a plan from a self-insured employer based in another state is legal. Some employers in Nevada are very large, are self-insured, and have headquarters based outside the state. These plans are not subject to the changing health insurance demands of every state since they are regulated by ERISA. So many Nevadans, despite state law, do not have coverage for their child’s ABA therapy.

 

It is important to note that self-insuring can reduce costs for employers, give them more control over the plan they design for employees, and can offer tax advantages along with easier implementation by reducing regulations and applicable laws. Employers should move in this direction to create better health plans that give them better access to their own data and needs. At the same time, we should recognize that these types of plans can be hard to regulate and present challenges to patients, employees, and lawmakers who want to see specific changes or policies. Employers should strongly consider self-insuring to get away from the profit motive of health insurance carriers, but should recognize that avoiding individual state health insurance requirements by self-insuring could lead to a backlash against self-insured health plans.
Another Note on Healthcare Brokers

Another Note on Healthcare Brokers

Posted on by jabittan
A point that Dave Chase makes in his book The Opioid Crisis Wake-Up Call is that employers are not fulfilling their fiduciary duties to their employees with regard to the healthcare products that they offer as benefits. I mentioned earlier that many companies have an HR person in charge of health benefits who doesn’t really understand health insurance and whose main goal is to not be yelled at by other employees for problems, high costs, and restrictions with their health insurance plan. The result has been a bit catastrophic, with plan costs rising continually, insurance companies and major healthcare systems ganging up on uninformed benefits managers, and healthcare brokers taking questionable bonuses from various arms of the healthcare sector.

 

David Contorno, founder of a company called E Powered Benefits, contributed a chapter to Chase’s book specifically highlighting many of the problems with the current broker arrangements that companies face. He writes, “Recently, a Blue Cross health plan offered their brokers a $50,000 reward for switching self-insured clients back to more lucrative, fully-insured plans. In sectors like financial services, that kind of undisclosed conflict could land a person in jail. In healthcare, however, such clear conflicts of interest are common and considered business as usual.” While this kind of broker arrangement is deplorable, the heat should not only be on the brokers. Employers are also responsible for ensuring they are partnering with brokers who are free from conflicts of interest, and there are groups now popping up to help employers identify brokers who don’t engage in such shady behind the scenes agreements with health insurance companies and healthcare systems.

 

Employers are responsible for the sound management of the financial resources they manage for their employees, whether it is retirement savings accounts or health insurance plans. Employers purchase and manage health insurance products for employees, however many of the healthcare decisions are made by people who don’t fully understand them, with the goal of not making people too angry, and with direction from actors who are not as independent as they claim. Chase worries that there could be an explosion of lawsuits against companies for operating in this system. Lawsuits holding companies responsible for out of control increases in healthcare plans could dramatically shake-up the way health insurance is provided and purchased in the United States. The bottom line is that as things stand now, the financial considerations of employees, the people who will use the product purchased for them, is not one of the main considerations in the purchasing of healthcare plans, and a lot of shady looking things take place among employer-broker-provider-insurer relationships.
Healthcare Brokers

A Hidden Obstacle in Controlling Healthcare Costs: Brokers

Posted on by jabittan
If you are a large company, you probably don’t have one person or department contacting various insurance agencies, hospitals, and pharmacies to get everything in place for the health insurance you provide to your employees. You likely work with a broker who is your agent in negotiating with insurance and healthcare companies. They help you understand the contract you sign with a carrier, and if you are going the self-insured route, they likely help navigate hospital and pharmacy contracts as well.

 

The broker you choose can greatly influence how much your company is going to pay for the health insurance provided to employers, for the administration of a self-insured plan, and even for individual services with providers. Brokers often position themselves as buyers agents, that is as representatives of the company looking to purchase coverage or administration, however, many brokers are simultaneously working for hospitals or for insurance agencies. What’s more, the hospital or insurance agency might compensate the broker more than your company, making the broker more of sellers agent than a buyers agent. Dave Chase highlights and explains this in his book The Opioid Crisis Wake-Up Call:

 

“Your business is just one piece of the total, but keeping it with the same carrier can boost the broker’s total compensation by 50% or more. Because this compensation isn’t specific to you, status quo brokers will often claim they’ve disclosed fees and commissions. But they are actually only disclosing your account-specific fees and commissions that may not even be the most significant piece of their overall compensation.”

 

If a broker is getting paid by an insurance carrier to keep your company with that carrier, then your chances of shopping around to find better alternatives are slim. Your broker is likely to encourage you to stick with your current carrier and accept whatever fee increase they present you with for next year’s coverage.

 

Chase continues, “Forward-looking brokers have sent me letters from insurance carriers saying they’d be fired when they spoke the truth about egregious practices the carrier was inflicting on the broker’s clients. This makes it clear that the carriers view brokers as a quasi-employee they can fire at will. In other works, they are working for the carrier, not your organization.”

 

The company that Dave Chase runs can help you identify trustworthy and high quality brokers. If you select a broker at random or just because you have a good relationship with them, you run the risk of working with someone who is not as independent as you think. The connections and world of insurance carriers and brokers is complex, and navigating it successfully on your own is challenging.

 

At another point, when addressing brokers, Chase writes, “You should always ask your benefits broker or claims administrator if a local hospital is a client, as that is a clear conflict of interest, especially when the hospital itself owns the insurance carrier.”

 

It is clear to me that the healthcare industry has too many entities that are tied together in unclear ways. If we hope to change the system in the future to be more equitable, to reduce prices, and to actually provide quality services, these status quo relationships will have to be broken up. That might be a task the government can solve, but Chase would argue that companies have the tools to do that work as well, they often just don’t utilize the leverage that they have.
Thoughts on Health Insurance Companies

Thoughts on Health Insurance Companies

Posted on by jabittan
Moving to a universal healthcare system with everything run by the Federal government might not solve all the problems in our healthcare system, and it might not really reduce all of our healthcare costs, but at least it would give us someone to hold accountable for rising costs, challenges with accessing care, and questionable quality of care. People across the United States are frustrated by healthcare providers and systems that seem to always be raising their costs and charging outrageous fees for basic medical care. Younger people today seem to find the idea of profiting on medical care to be slightly unethical, and health insurance company practices do a lot to increase people’s discontent with the current system and actors. In short, a lot of people probably just want to move to universal coverage provided by the government just to simplify the process and cut out insurance companies, especially when the average consumer can’t understand what benefit the insurance company provides.

 

These thoughts about our discontent with our current system came to mind this morning after reading the following passage that I highlighted in Dave Chase’s book The Opioid Crisis Wake-Up Call. Chase writes, “If you’re a fully insured employer and have higher-than-expected claims in one year, your insurance carrier will work to get as much back as possible in subsequent years through larger premium increases.”

 

What Chase describes is something that not everyone is directly aware of or able to explain, but it is something many of us have a vague feeling of or intuitive expectation of. Rather than existing as organizations to help us be healthy, rather than trying to solve a problem, rather than caring about our health needs, many people simply see health insurance as stealing a few bucks from them, their employers, their providers, and from people who really need medical care. Insurance companies are seen as morally unethical, powerful government lobbiers, and as bureaucratic machines that treat everyone like numbers.

 

If you are not in favor of a public health insurance program, and if you think that private insurance is the way to go, ask yourself what the industry could do better to actually provide value to patients. If you are in a health insurance company and think you do provide value to your patients, ask yourself, why don’t people see it? Perhaps we only see the games that insurance plays to limit access to care, to increase premiums every year, and to squeeze hospitals and providers, causing us to misunderstand the benefits that insurance provides. If private health insurance really wants to survive in the future, the industry needs to do better at showing its value, and minimizing its greedy tricks, otherwise, you can’t blame the public for wanting to eliminate insurance companies and have an accountable government take on universal coverage.
Health Insurance Company Games

Health Insurance Company Games

Posted on by jabittan
Dave Chase’s book The Opioid Crisis Wake-Up Call was an interesting read because Chase highlights many of the health insurance company games that add to the cost of healthcare in the United States without providing additional value. I’m skeptical of health insurance companies, and Chase’s book discusses some of the nitty-gritty details of misaligned incentives that lead to unending increases in healthcare premiums and costs.

 

An example that Chase highlights is early renewal discounts for companies that chose to stay with their current health insurance company or plan administrator. Throughout the book, Chase discusses how businesses are letting their employees down and allowing healthcare costs to skyrocket by accepting increasing healthcare costs from health insurance companies each year. Many companies don’t have someone who really understands healthcare or health insurance in charge of their benefits programs, and as a result those individuals are often more focused on not being yelled at by employees than on reducing costs and providing a valuable health insurance package. Insurance companies take advantage of this by pressuring businesses to accept increases in the cost of healthcare administration each year at rates far above inflation.

 

Insurance companies know that businesses don’t actually want to shop around for health insurance and they know that employees don’t want to have a change in insurance each year. Insurance companies will offer benefits for early renewals from companies, and as Chase writes, “Often these early renewals come with no-shop clauses. So, a 20 percent rate increase may only be a 15 percent if you sign today and agree not to shop the competition. This should be viewed as a red-flag, not a great deal on a premium reduction.”

 

Insurance companies position themselves as offering a good deal, but they are increasing the cost of the insurance plan by 15%. Busy employers with small HR staff often see this as a win because it reduces their effort and while employees see costs rise they don’t have to hassle with changing insurance and unknown insurance processes. This is part of why premiums in the United States are rising so fast. Insurance companies hide information and data, and make it difficult for overwhelmed staff to pick benefits that will truly help employees.
Pay and Chase

Pay and Chase

Posted on by jabittan
If you were working to set up a healthcare plan for your employers, you would want to make sure that payments by the insurance plan were quick so that your employees were not constantly bombarded by letters and phone calls from doctors offices asking when they would be paid by the insurance plan. You also would want the plan to have a system in place for catching fraudulent claims or errors in charges from hospitals and doctors offices. Both of these desires are reasonable, but in the real world, they have created a system of perverse incentives that Dave Chase calls “Pay and Chase” in his book The Opioid Crisis Wake-Up Call. Here is how Chase describes it in his book:

 

“Another fee opportunity is so-called pay and chase programs, in which the insurance carrier doing your claims administration gets paid 30-40 percent for recovering fraudulent or duplicative claims. Thus, there is a perverse incentive to tacitly allow fraudulent and duplicative claims to be paid, get paid as the plan administrator, then get paid a second time for recovering the originally paid claim.”

 

Insurance companies administering health insurance don’t actually have an incentive to create tools to proactively stop fraud. They actually benefit when there is fraud, because they get a bonus when they spot the fraud and recoup the already paid fraudulent amount. As an employer partnered with the insurance company, you might be happy that claims are paid quickly so that your employees don’t have negative interactions with doctors about payment, but the way that many plans currently operate, you will end up paying a lot more overall when your plan pays for fraudulent claims and billing errors. You will pay for the fraud itself, and if you get any money back, it won’t be for the full amount that your claim administrator originally paid in the fraud or error – they will keep a cut.

 

Chase continues, “Many of the fraud prevention tools used by claims administrators are laughably outdated and weak compared to what they are up against. Modern payment integrity solutions can stop fraud and duplicate claims, but aren’t being used by most self-insured companies’ claims administrators.”

 

Poor incentives and confusing systems have allowed this to occur. This is one example of how the systems around healthcare in the United States are not aligned with what we would all agree should be the number one focus: improving the health of Americans. Employers don’t want their employees to be angry, and plan administrators want to maximize profits. In the end, we all pay more as fraudsters find ways to get past the outdated fraud prevention systems of insurance companies and as those companies turn around and charge fees for catching the fraud and payment errors they didn’t prevent in the first place.
GoFundMe For Healthcare

GoFundMe for Healthcare

Posted on by jabittan
We all complain about our personal healthcare costs and we know that healthcare spending in the US is a huge percentage of GDP, but what isn’t clear is that the vast majority of spending and healthcare costs come from a small minority of patients. Cancer care, treatment for severe trauma, and therapy for rare diseases can be incredibly costly and unpredictable. For many people who face such substantial challenges, GoFundMe ends up being a huge support, and I think it is worth asking ourselves if that is a reasonable way for people to be able to afford medical care in the United States.

 

As Dave Chase writes in The Opioid Crisis Wake-Up Call, “In 2013, more than 1.5 million Americans lived in households that experienced a health-related bankruptcy. More than three-quarters of those people had insurance. Some say medical bills may also be the top cause of homelessness. Nearly half of all GoFundMe crowdfunding campaigns are to pay for medical-related expenses.”

 

Our health insurance, what we pay for and what our employers offer us to help ensure that if necessary, we can afford medical care, does not actually help us afford medical care in the case of an emergency or major diagnosis. Medical related bankruptcies are not a rare occurrence, even for those who have insurance, and if Chase’s quote is accurate that a large cause of homelessness is medical bills, then the cost of care that is supposed to help someone be healthy, likely pushes people into incredibly unhealthy living circumstances. The fact that people have to turn to crowdfunding moonshots for treatment is a clear indication that the healthcare system in America is failing those who need it most.

 

I would argue that much of the social unrest in our country is related to stagnated wages. Chase argues that wages have stagnated as businesses cope with increasing costs for providing healthcare to employees. Americans don’t see their wages increase, but do see the cost of healthcare rising, and many face bankruptcy and must turn to GoFundMe for healthcare related expenses. It is not hard to imagine how healthcare costs contribute to an unhappy populace that doesn’t trust public officials and elected leaders who have not been able to remedy the situation, or business leaders who have not provided real value in the health benefits they offer employees.