Saturday, December 30, 2006

MetLife Latest to Pay for Contingent Commissions

MetLife is the latest to settle with New York Attorney General Spitzer for its use of contingent commissions. With UnumProvident and Prudential Financial already paying millions in fines and restitution to customers, MetLife will now pay $16.5 million to policyholders and $2.5 million in New York penalties.

What is amazing is how long all of this has gone on. For years after the scandal first broke, the contingent and unreported commission practice has continued. Smaller benefits brokers and benefits consultants continued to insist on these behind the scenes incentives to put more business with a particular company long after one would have thought the threat of embarrassment and common sense would have prevailed.

The ERISA required form 5500 always required full disclosure. Yet the industry ignored it. Insurers paid, brokers and consultants collected, and employers looked the other way.

Things have been particularly bad for my old company––UnumProvident. They not only got caught up in this as the benefits commission payment poster child for sleeze, but paid another set of fines and settlements to state insurance departments for even sleazier claim practices.

The chickens always come home to roost!

Anyone still on the take with these back room commission deals would be wise to pay attention.

Tuesday, December 26, 2006

Why is Health Care Cost Trend So Low?

In my last two posts (below) I pointed out that commercial medical cost trend has been reported to be as low as 5.5% to 6% with most employers reporting 2007 increases in the 7% to 8% range.

While employer trend rates are at this level, health plans are reporting even lower internal trend rates with commercial profits remaining strong and virtually all of the plans reporting rate increases ahead of actual costs (see article below).

Which raises a question: Why is health care cost trend as low as it is?

In past years, higher rates of trend tended to reflect high rates of utilization that made up perhaps two-thirds to three fourths of the trend rate. The remaining trend was made up of pure price trend. So, if trend was 12%, perhaps 4 points of that was pure price trend and 8 points was utilization––in round numbers.

Could it be that the actual trend rates being experienced by the health plans today are made up of perhaps 4 points for price inflation and 2 points for utilization––again in round numbers?

Are we seeing lower trend rates because we are experiencing lower rates of increase in utilization?

After years of high increases in utilization by providers––particularly in the wake of the "provider backlash" (or patients' rights rebellion) in the early part of this decade and a slower rate of new technology and drug introductions––are we seeing a fundamental slowing in health care costs?????

Thursday, December 21, 2006

HMOs Better Negotiators Than Employers for 2007

"Benefit consultants and brokers are reporting that medical trend rates are continuing to fall - to the 7% to 8% range - while health plans are reporting that their actual costs are trending as low as 5.5% to 6.5%."

That's the lead in an article I wrote that was published in this month's issue of Employee Benefit Adviser.

In it, I reviewed the third quarter HMO earnings reports and compared them to the trend rates employers are paying for their health plan renewals.

You can also access the entire article at:

Tuesday, December 19, 2006

Cost Trend..How Low Will it Go?

Health Care Cost Trends

Last month I asked, just how low will medical cost trend go?

Apparently, still lower.

Health care cost trends have been falling for a number of years since peaking in 2002 at around 14%. Recent reports have annual commercial health plan trend as low as 5.5% to 6.5% in a few places.

The good news about lower health care cost trends continued as publicly traded health plans reported their third quarter results. Most health plans reported falling medical cost ratios on a constant basis, favorable claim development from prior periods, and pricing trend continuing to outpace actual pricing trend.

Once again for the third quarter WellPoint reported that the trend they are pricing into their contracts is greater than the actual cost trend they are experiencing: “Commercial premium yield exceeded total cost trend…resulting in an increase in underwriting margin.” Coventry reported the same thing saying, “Commercial premium yields showed a favorable price-to-cost spread in the third quarter.”

This month, the Federal Employee Health Benefits Program (FEHBP), which covers eight million federal workers, retirees, and their families, said it would increase overall premium by an average of only 1.8% in 2007.

The federal program has historically tracked with private sector costs—albeit at slightly lower levels. The FEHBP saw increases of 12.7% in 2002, 11.3% in 2003, 9.5% in 2004, 7.4% in 2005, and 6.4% in 2006. Granted, some of this is reserve adjustments from prior years but this is still surprisingly low.

A leading employee benefits firm, Hewitt Associates, LLC, also said that their survey of employee benefits costs found that employer costs would continue to moderate in 2007. Hewitt projects employer costs will rise 7.7% in 2007—7% for PPO plans, 8% for HMO plans, and 9% for point-of-service indemnity plans.

However, the drop in trend is not uniform around the country. Hewitt reports trend increases as low as 2.5% in Minneapolis, 5.7% in Philadelphia, and 6.5% in New York City. They also report trend rates as high as 13.1% in San Antonio, 12.8% in Hartford, and 10.5% in San Francisco. Last month, the Boston Globe reported Massachusetts would see at least a 10% trend rate for the seventh year in a row.

Third quarter publicly traded health plan results confirm that health plans continue to rack-up record profits on the heels of declining claim cost trends. The health care cost trend profit windfall, coming from cost trends falling faster than pricing trends, continues on.

From the Hewitt survey, it is clear that not all employers (and their employees) are benefiting from the full benefit of these declining trend rates.

While the news about trend rates is improving, that doesn’t mean health care costs are any more affordable for workers. The Kaiser Family Foundation annual survey of health insurance now pegs the average cost of family health insurance at $11,480 per year.

Even with the relatively moderate rise in health care costs for 2007 employer health care costs will have doubled since 2000.

The 2007 Congressional Health Policy Agenda

The Congressional Agenda—Old Business

The current Congress is leaving a lot of work undone:
• A Health Information Technology (HIT) Bill – The old Congress will not be able to complete work on the House and Senate versions of a HIT bill. Before the election, they had hoped to be able to finish it during the “lame duck” session. It is now clear that won’t happen and the new Congress will start from scratch on the issue next year.

That means the Congress has not implemented a requirement that payers and providers will have to use the new ICD claim-coding system by 2010. It also likely means Democrats will be more worried about privacy protections and less worried about giving hospitals more control over the development and financing of the new systems as the Republican House bill would have done.

The new Congress will start from scratch on a new HIT bill.

Medicare Physician Fee Cuts – Republicans had hoped to find the money to waive the 5% physician fee scheduled to take place on January 1. Helping the docs out before January 1st is likely another casualty of the election. That is not to say the Democrats don’t want to help the physicians—they do. But the Democrats can’t get to it until early next year and when they do, it will be private Medicare plans that will likely produce the needed cash.

New Business in a New Congress
The old Republican favorites—expansion of health savings accounts, Association Health Plans, and medical malpractice reform—are out and new Democratic agenda items are in.

This is where many of the analysts are right—with a Bush veto and the 60-vote rule in a Senate that has 51 Democrats—it will be very difficult to do more than tread water on new non-budget health care proposals.

Here’s a look at the new agenda:

Medicare and the Drug Companies – House Democrats say they will pass legislation enabling Medicare to negotiate drug prices directly with the drug companies in the first 100 hours of the new Congress. They will. And then the bill will likely languish in a more divided Senate. If it does get past the Senate—which is not likely but not impossible either—Bush will veto it.

Drug Reimportation – This was a big Democratic issue during the election. I wouldn’t be surprised to see the Democrats couple drug reimportation and giving Medicare the power to negotiate drug prices into one bill all designed to attract a Bush veto for what are popular—if not controversial—proposals.

• A Patients’ Bill of Rights – You read it correctly. House Energy and Commerce Committee Chair John Dingell has this one on his list of things to do next year. Apparently, he didn’t get the memo this one is off the voters’ list of worries. It probably won’t get very far but there might be some HMO bashing hearings—perhaps focused on Part D issues.

The Uninsured – Now up to 46 million, look for the Democrats to tackle this issue more directly. That effort was helped by a health insurance industry proposal from America’s Health Plans (AHP) that called for the expansion of Medicaid for the lower income (which the Democrats liked) and the creation of tax credits to help others (which the Republicans liked).

However, the AHP proposal has a $300 billion price tag and no strategy for cost containment.

While that specific proposal won’t likely go very far in the near-term, the AHP did itself well by jump-starting a discussion about incremental solutions that combine both a private and public effort.

By being incremental and building on existing programs and ideas that both sides can embrace, the insurance industry proposal may become the seed that started a constructive discussion for the longer term.

Medicare Reform – The “Part A,” hospital portion, of Medicare is expected go into negative cash flow in just three years as the baby boomers begin to be eligible for the program.

Under Republican leadership, the likes of House Ways and Means Chair Bill Thomas have dominated the discussion with his market-based proposals and the 2003 Medicare bill.

Now, it will be the Democrats who will dominate the Medicare discussion with their agenda setting committee chairmanships. They give every indication of wanting to dive into the program and its various challenges from provider reimbursement to private plan payments.

Part D Profits––Not Yet the Great Results the Industry Hoped For

Part D—Some Results Starting to Come In
To say the Part D business has been controversial this year would certainly be an understatement. It’s not news that many in the industry have questioned its sustainability as a business—including me.

During 2006, the profitability data hasn’t been credible. In fact, it will likely be another year before we get a good sense for what’s really going on. While the players had to bid their 2007 rates earlier this year, most of what they based them on was pretty soft.

However, the third quarter was supposed to be the quarter that Part D profitability would spike as the sickest seniors would be in the gap and Part D claim levels would therefore decrease for the rest of the year. There is evidence that is happening. But, is it happening enough?

The biggest Part D player is UnitedHealth. In the second quarter, they said, “The Part D business is well on track to provide positive contributions to earnings on a GAAP basis in the third and fourth quarter and meet its full-year operating margin target of 3% to 4%.”

But their outlook was less specific in the third quarter, “On a full year basis, management estimates that Medicare Part D will generate a positive operating margin, however as a result of the benefit design, generated a slightly negative margin during the first three quarters of 2006.” No more specific earnings estimates and no report of big Part D profits in the third quarter.

The second largest Part D insurer, Humana, was less oblique about its Part D results. Given that the third quarter was supposed to be the quarter that the “gap” turned Part D profits around and produced a profit, their results are somewhat startling. Humana reported that, The MER [medical expense ratio] for the company’s PDP [Part D] business was 93.0% for 3Q06, primarily driven by an MER of 133.0% in the company’s Complete [“gap” plan] PDP offering.” The expense factor for Part D plans is likely about 15%. That means that Humana’s Part D combined ratio in the third quarter, the quarter the profits were supposed to show up, was likely 108%!

It is clear that Humana blew it on its “Complete” plan that provides brand name drug coverage in the “gap.” It gets back to the anti-selection argument. Seniors had the ability to pick the plan they could make the most money on, and hundreds of thousands zeroed in on Humana’s rich offering.

Humana’s response has been to double the 2007 senior premium for this plan and stop covering name brand name drugs in the “gap.” They will continue to cover generic drugs in the “gap.” However, with a monthly price of about $80, seniors can find competing generic “gap” plans for about half of that price. Humana clearly intends to blow these much higher utilizing seniors not only out of this losing plan but also out of the company all together. Remember, I told you that the Democrats now have “oversight” powers? This one is going to be the subject of oversight hearing number one.

The great majority of the Part D renewal process appears to be running well. Most plans are increasing their premiums by less than $5 per month and most seniors are happy with their plan and will stay put.

But the Humana “Complete Plan” is going to get the attention. Any Democrat that wants point to some market warts on the way to justifying more regulation and lower payments to private Part D plans is going to point to Humana—a company that tripled its profits by getting into MedicareAdvantage and then used its price strategy to churn the sickest people out of its Part D program.

The longer term Part D concern for the health plan industry has to be that, in the first year, it is turning out to be marginally profitable at best (United) and a real profit loser at worst (Humana). Looking ahead to at least two years of Democratic budgets and oversight, it can only go downhill from here.

The Democrats Will Change MedicareAdvantage

So, Now What?

Most observers don’t think the Democratic takeover will end up meaning a lot. It takes 60 votes do get anything done in the Senate, there is still a Republican presidential veto to contend with, and Democrats would be foolish to rollback the Republican tax cuts or repeal programs like the Part D Medicare drug benefit or the new private Medicare Advantage plans that now have millions of generally happy senior enrollees.

In fact, Goldman Sachs analyst Mat Borsch came out with a positive report on Humana, a company that has been particularly aggressive in the Medicare market. Borsch said that while it is possible Democrats would change the Part D program, “the odds of substantial change to the Medicare Advantage plan program (which is what really matters to Humana) are remote.”


Why Democrats Hate Medicare Advantage
Let’s review some of the history.

The profitability of MedicareAdvantage plans is what really matters not only to Humana but also to most major health players who have aggressively entered that business.

In fact, Humana’s government profit center reported that MedicareAdvantage enrollment grew to 993,000 from 489,000 a year earlier. Almost all of that growth was in the private fee-for-service product subset. Humana also reported a pre tax MedicareAdvantage profit of $207 million in the third quarter—up from $87.9 million in the same quarter of 2005.

Part D was always the thing the industry had to agree to in order to get the fantastic deal they have with MedicareAdvantage.

The Medicare Payment Advisory Commission recently said that private MedicareAdvantage plans get an average of 11% more for their seniors than the traditional Medicare plan gets for its enrollees. The Republican Congress did that intentionally in 2003 in order to attract private plans back into the private Medicare program after many either cut back or left it altogether in the wake of sharp cuts in the 1997 budget.

This “prime the pump” strategy made sense to Republicans who wanted to begin the reform of the traditional Medicare program by encouraging HMOs to bring market forces to bear on the exploding cost of the program.

But most Democrats hate the idea.

It gets down to a fundamental difference between the two parties. Republicans generally believe that a government-run plan and quality/efficiency are mutually exclusive and the value of market forces are at the core to any successful reform.

Democrats generally believe that Medicare has worked well and the market will only want to skim off the best risks and divide Medicare into two programs. They worry that the Republican “defined contribution” private market strategy will stratify Medicare enrollees by what they can afford to pay. Ultimately, they argue, the best quality plans will cost more and be affordable only by the well off. Those who won’t be able to afford premiums set by the market for the best plans will be forced to remain in what will become a second class Medicare plan, or plans that will look more like today’s Medicaid.

Many Democrats, and the House Democratic leaders in particular, believe that the universality of Medicare is absolutely critical. The logic is that you need to have the rich and powerful in the same pot as everyone else if you want to have equality in health care.

What many of these financial analysts on Wall Street don’t understand (Humana is trading at the highest price/earnings multiple in the HMO industry) is that, to the Democrats, this is not just about a fair funding level for private Medicare plans and whether they want to risk messing with them. It is about deep-seated ideological objections.

On top of all of this, just how Humana is making its extraordinary profits only compounds the Democrats’ ire. Almost all of Humana’s MedicareAdvantage growth this year has been in the Medicare fee-for-service product (MFFS). This is the product that does not allow insurers to negotiate lower provider reimbursement rates. To its critics, it is almost entirely an arbitrage play letting insurers take the 11% higher reimbursements, spend some of it on higher benefits for seniors to get them interested in the plans, and take the rest in profit. MFFS is hardly proof that the market can manage Medicare better than the government.

Industry logic that sees MFFS as a means to gradually transition seniors into more sophisticated products where insurers can apply medical management and provider negotiation hasn’t impressed the Democrats.

To a great many Democrats, and in particular their leadership, this is about throwing a wrench into the Republican vision of what Medicare will look like in the coming years—a vision that these Democrats see as a “Republican sell-out” of the longstanding Medicare entitlement promise and an “egregious example of taking care of their corporate friends.” They put Medicare fee-for-service right on top of their list.

To throw that wrench in the works, the Democrats don’t need to focus on a presidential veto threat or even worry about 60 votes in the U.S. Senate. They don’t even have to risk senior ire by outright trying to kill the new private Medicare plans.

They only have to look to Republican Newt Gingrich for their anti-market Medicare strategy. They just need to set it up to “whither on the vine.”

It’s the Budget, Stupid!

They can do that, rather easily as it turns out, in the budget process. A budget is not subject to the 60-vote rule in the Senate. A budget can be vetoed, but would Bush veto a gigantic budget bill over this issue? More likely he would compromise on the size of the cuts—not critical to a longer-term “wither on the vine” strategy.

The Democrats’ victory in the Senate turns out to be very important here. With just one slim vote, the Democrats now control the committees in both houses—and control any House/Senate conference on a budget.

used control of the conference structure to enable their leadership to dictate just what went on the table and which members got to be part of the conference. The minority party is almost always frozen out. Passing a bill in the House is one thing, passing a bill in the Senate is another, but controlling the conference, who gets to vote, and just what gets considered (even things that had not been passed in either house in the first place) is at a whole different level.

It is true that most of the new Democrats are moderate or even conservative Democrats on many issues. However, the budget is where MedicareAdvantage and Part D payment levels and benefits are decided and that process is one big black hole that will be controlled by the long-time liberal Democratic chairmen who just literally hate these programs. That’s where the likes of powerful Democrats John Dingell, the longtime Democratic Chair of the House Energy and Commerce Committee the last time around; Henry Waxman, who will have government operations oversight; Charlie Rangel who will lead Ways and Means; Pete Stark, who will head-up the Ways and Means Health Subcommittee; and Ted Kennedy, who will again chair the Senate Health, Education, Labor, and Pensions Committee, will control the agenda.

And, don’t forget oversight. These Chairmen will have the ability to nitpick these programs to death with their influence over the regulation of these plans and things like benefit schedules.

The only friendly Democrat the health plan industry has to talk to is the incoming Senate Finance Chair Max Baucus (D-MT). He worked closely with his friend, outgoing Senate Finance Chair Chuck Grassley (R-IA), to pass the 2003 Medicare bill in the first place and has defended it ever since.

Sure President Bush would veto any bill that did away with Part D, or MedicareAdvantage, or cut their financing.

But there won’t be such a standalone bill.

There will be some giant spending bill that will have lots of gives and takes in it. Maybe, Bush would risk a veto of the whole thing if it cut MedicareAdvantage plans by that 11%. But would he risk a veto of a big budget bill if it cut the HMOs by 5% and upped the benefit schedule in Part D and MedicareAdvantage? Not likely.

Not only do Democrats want to cut the private Medicare funds because they don’t like them, they need to cut them to find money to do other things.

One thing that is certain about Congress—Democrat or Republican—is that when it needs money it always comes looking to take some from the Medicare providers. How many times have we seen Republicans and Democrats cut doctors and hospitals to balance the budget—especially when either was seen as well compensated?

Now, HMOs are Medicare providers too and they are seen as fat with lots of great reimbursement. Just listen to Humana’s CEO talking about his profits tripling in the third quarter, “This quarter’s biggest takeaway is that our Medicare strategy is working.” That sounds great in the investment community but he’s asking for trouble in Washington.

It may get even more problematic for the HMOs in a way I wouldn’t have predicted just a few weeks ago. The current Congress has not completed its 2007 budget for the Medicare program. There is talk that Republicans may not even try to finish it and instead punt it to the new Congress. That means that instead of Democrats getting their first Medicare budget in late 2007, they may get their first whack at the HMO Medicare payments in January!

The HMO Medicare business is seen as highly profitable just as doctors are in a bind. Because of the Medicare Sustainable Growth Rate Formula, Medicare physicians are scheduled for a 5% fee cut on January 1, 2006. They are scheduled for a total of 40% in cuts over the next five years. Democrats, like Republicans, want to help the doctors out, and they need a place to get the money.

Beyond that, there is a $3 billion shortfall that has been identified to pay for the Labor/HHS spending bill the 2006 Republican House passed. There is a $5.5 billion gap on all unfinished appropriations bills.

Then there is the cost of fixing the Medicare physician fee cuts. Before the Congress adjourned this month, they took $7 billion from the MedicareAdvantage stabilization fund and used it to offset scheduled Medicare physician fee cuts.

The Democrats made lots of other election promises that cost money and those profitable HMOs present one terrific target.

The good news for the health plan industry is that it’s making loads of money in the MedicareAdvantage business.

The bad news for the health plan industry is that the timing for a Democratic return to power couldn’t be worse for them.

The first budget target was the MedicareAdvantage stabilization fund—originally budgeted to be $10 billion. Since it hasn’t been necessary to stabilize anything so far, that is easy money for the industry to give back.

With $7 billion of that already gone (and it was the Republicans that gave that back!), any more givebacks are going to be real money.

Why the Republicans Lost

After six years of one-party government, things here in Washington were getting kind of boring.

That’s already started to change.

The November Election

In past years, I have told you that the chances the Democrats could capture the House of Representatives were low because of all the highly political gerrymandering of districts that took place in the wake of the 2000 census. That redistricting made the vast majority of House seats permanently safe for the party that controlled it. Because of all of this, perhaps only 45 seats would really be in play in any election year.

Those odds made the Democratic victory in the House this month all the more impressive.

But perhaps even more surprising is the Democratic sweep of Senate races giving them a one-vote advantage in that body.

The single issue that dominated the elections was Iraq but it goes even deeper than that.

Marlon Brando and the Republicans
There is this old Marlon Brando movie—“Zapata,” that’s the story of the Mexican revolutionary period at the turn of the 20th century. The movie starts out with the corrupt government shooting the peasants. The movie ends with Marlon Brando’s revolutionary character playing a key role its overthrow and with the new guys shooting the peasants.

The Republicans had their own revolution in 1994. They lost this election because they ended up shooting the peasants.

The Republicans forgot that 12 years ago the electorate threw the Democrats out because the swing voters came to the conclusion that after decades of control, the Democrats were out of touch (the Clinton Health Plan) and had been corrupted (the post office scandal, House Ways and Means Chair Dan Rostenkowski in jail, and various other problems) by their power after many years of unilateral control of the government.

In 2006, the Republicans got the boot because they were seen to be out of touch (Iraq) and corrupted (Folly, Abramoff, and “ear marks”) by the power coming from their almost complete control of the government.

In short, power did to the Republicans exactly what it had done to the Democrats by 1994, and the result was the same.

The toughest criticism of the Republicans has been coming from leaders in their own party:
George Will on why Republicans lost the election in his weekly column on November 12: “Tuesday’s election results were fresh evidence that two events that profoundly shaped American politics during the last two presidencies were episodes of irrational exuberance unrelated to economic behavior.” Later in the piece, “The Democratic episode was the Clintons’ attempt to radically restructure and semi-socialize the 16 percent of the economy that is the health care sector. The Republican episode is Iraq.”
Dick Armey, the former House majority leader and Gingrich chief lieutenant during the 1994 Republican takeover, in a October 29 op-ed in the Washington Post on why the Republicans were on their way to a loss: “The answer is simple: Republican lawmakers forgot the party’s principles, became enamored with politics over policy. Now the Democrats are reaping the rewards of our neglect—and we have no one to blame but ourselves.” Later in the same article, “Now spending is out of control. Rather than rolling back government, we have a new $1.2 trillion Medicare prescription drug benefit, and non-defense discretionary spending is growing twice as fast as it had in the Clinton administration.”

“Zapata” should be mandatory viewing up on the Hill.


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