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Health insurance is a complicated topic. I’m in the business, and I struggle at times to understand the benefits, the coverages, the rules and the jargon. And as health care changes, the health insurance business changes right along with it.
Harvard Pilgrim’s also gone through a significant amount of change over the past few years. When I joined the plan in 1999, over 90 percent of our members were in HMO products - that is, products that required choosing a Primary Care Provider and receiving a referral from that physician before seeing a specialist. Today, about 70 percent of our members are in HMO products, while the other 30 percent - about 300,000 members - are enrolled in PPO products, which don’t require a Primary Care Provider or a referral to see a specialist. Our provider network’s also changed quite a bit. While it was once pretty limited, there are very few physicians or hospitals in Massachusetts, New Hampshire, Maine or Rhode Island who aren’t in our provider network today. Overall, we have about 28,000 physicians and other providers in our network in MA, NH, ME and RI, and about 135 hospitals - which makes our provider network across these four states as big as anyone else’s, including the Blue Cross plans in each of these states. And we can reach physicians and hospitals around the rest of the country through our alliance with United Healthcare, which has hundreds of thousands of physicians outside our service area, and thousands of hospitals, too. And our pharmacy network covers the entire country, including virtually every pharmacy in MA, NH, ME and RI, where we do most of our business. We hope this site can give anyone who’s got an idea or a question about health insurance and/or health care an opportunity to share it with us, and with anyone else who chooses to participate in “lets talk health care.” The rules on the site are pretty simple - keep it simple, keep it clean, and while it’s perfectly fine to be tough-minded on the topics we’re discussing, let’s try to be easy on each other. Disagreeing without being disagreeable is our watchword here.
Dear Charlie,
Welcome to the medical blogosphere! We’re glad to have you join the think tank. My favorite healthcare bloggers are:
Dr. Richard Reece at Med Innovation Blog:
http://www.medinnovationblog.blogspot.com and
Dr. Stanley Feld at Repairing the Healthcare System:
http://www.stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/
And I blog about a wide variety of topics, from healthcare issues, to breaking news, to personal stories at: http://www.revolutionhealth.com/blogs/valjonesmd.
As the Senior Medical Director at Revolution Health I really enjoy learning from the wisdom of those who have devoted their lives to improving healthcare in this country.
Let’s work together to make changes that will truly impact patients for the better!
Warm Regards,
Val Jones, MD
This blog will attact many technical questions about Mass Health Care Reform, HPHC’s products, costs and the like. All this is as it should be, but blogs can have more “blue sky” to them.
HPHC has been a leader in so many ways for so long; how will you change the course of reform in Massachusetts?
Is there really any room for that to happen?
What does Charlie Baker see as the impact of Massachsetts Health Care Reform on the US?
What impact with Reform have on the Costs of health care?
The US Government publishes a report that says there are 85,000 illegal aliens in Massachusetts. How will these people get their health care after 7/1/07?
Welcome to the blogosphere, Charlie! I hope your visitors will also check out the provider viewpoint at http://www.runningahospital.blogspot.com
Welcome Charlie,
Good to see another health plan guy entering the blog world. I’m an SVP at the Blue Plan in Hawaii and also do some health care blogging at http://www.ajfortin.com Let’s stay in touch.
Fred
This is wonderful, but I’d have preferred if you were blogging from The Corner Office.
Charlie nice to have you on board. It will be a great challenge to a good many-
In my professional capacity as a consultant as well as my personal capacity as a patient, I am always looking for the least invasive, most cost-effective treatment available to both the patient and payor.
Two noteworthy of review: the Graston Technique/SASTM Sound Assisted Soft Tissue Mobilization a form of cross-fiber massage incorporating instruments to detect what the human hand is unable to. The technique is used by trained physical therapists, chiropractors or athletic trainers wherein instruments identify, treat and release the scar tissue associated with soft tissue injuries, trauma or surgery; result 85% resolution. Simple stretching exercises and ice help remodel the tissue. Most folks respond in 11 visits or less. It can reverse the need for sx related to or resulting from the majority of tendonitis, tendenosis, and carpal tunnel syndromes. Used in the professional sports world and in some of the best hospitals around. It’s something that MD’s and patients should be made aware of as both a preventative and resolute option (and I am not affiliated with the technique, I do write about it) The capacity to reverse dysfunction and prevent unnecessary surgery is unmatched.
Also, Chiropractic- even Harvard has created a clinic for the study of- headed up by Matt Kowalski DC. I have found very little validity in the traditional method of management of this benefit: x number of visits or x dollar amounts- Chiropractic can and should be managed and measured based on patient outcomes, controlled through severity risk factors and measured against the cost-benefits of minimized drugs, hospitalizations and surgeries. There is a difference in the philosophical belief system just as significant as the clinical technique used ie thrust-based verses mechanical, which greatly impacts patient result. It can do a great deal of good if /when managed properly to keep and help restore function and control pain.
These two minor enhancements/additions affect the capacity for patient function and to control pain management. In my experience they make a big difference to a great many people and to any insurer’s bottom line.
Charlie –
I just learned from Paul Levy’s blog that you have taken the leap. Welcome to the blogosphere!
– David
http://healthblawg.typepad.com
Here is my idea about how to move forward;
We need to have a single party payor for catastrophic health problems. Catastrophic health problems should be defined by expert panels that consist of people who actually practice medicine in their respective fields, (not just talk or write about it), lay people, ethicists, health economist and academics. Notice, I did not include insurance company representatives. The single party would be the federal government, (it is aready paying for such care indirectly).
We need to then have medical savings accounts with means testing for “non catastrophic health care”. Individuals and families who test will have a government subsidy (part federal, part state) that will allow them to purchase a plain vanilla plan. Such a plan will insure access to a primary care provider, (industrialized countries with a high percentage of health providers who are primary care have higher health standard measurements).
The insurance companies can then provide plans that will address non catastrophic health care. The cost of such insurance should be a small percentage of current premiums and thus more affordable. They will not be allowed to participate if they attempt to exclude people on the basis of prior illness, age, sex or any other reason they dream up.
We will not make progress as long as our health care future is influenced by large publicly traded companies who preach an interest in health. The truth is, Americans are not healthier as a result of the involvement of the Aetna’s and United Health Cares of the world.
This is all very new - and remarkably interesting. First of all, special thanks to BIDMC CEO Paul Levy for getting into this game early and encouraging others to hop in behind him. I find his stuff easy and fun to read, and hope I can bring 10 percent of the creativity he brings to this game.
Gerry B. - in response to your questions, I would say the following…First, health care reform in MA is happening, with or without my input. HPHC is pleased to be one of the carriers selected by the Commonwealth’s newly formed Connector Authority to offer products to those folks who qualify for Commonwealth Choice coverage, and we have plenty of thoughts about how to make it succeed - but this trains out of the station, the horse has left the barn, etc. As far as the national influence issue is concerned, I think everyone in MA would be much better off if we all STOPPED THINKING ABOUT WHAT OTHERS OUTSIDE MA WILL THINK OF OUR REFORM PLAN AND JUST DO WHAT WE THINK MAKES SENSE HERE IN MA. I find it both frustrating and annoying that so many people involved in this debate here in MA rely on and pay attention to what others who have no practical stake in this reform plan at all have to say about it. “If we don’t do this, the national audience will blah, blah, blah…” Let them. If they want to know about how we’re doing, they can come here and engage for a few days. In the meantime, let’s stop worrying about how our plans and decisions look to specific segments of the national advocady and media communities and do what we think makes sense for the people of Massachusetts.
And finally, Gerry, there is nothing - NOTHING - in the health care reform bill that will specifically slow the rist in health care costs or health care premiums. It has two features, however, that might make a difference over time. First, it allows plans to offer so-called “narrow network” health insurance products, which means that some of the plans people will select don’t include all hospitals and physicians in MA. This is a good thing. People can get excellent care from many hospitals and providers in MA. No one needs them all. And in many cases, reducing the size of the provider network by a small number of providers (a few hospitals and a handful of physician groups) can translate into significant (5-15%) reductions in health care costs and health insurance premiums. Second, the reform act did create a Health Care Quality and Cost Council (which I was appointed to), and gives it the authority to collect information on health care costs and quality, and make it available to the public for review and discussion. It is only by bringing this information to the public dialogue that we have any chance of having a sensible, informed conversation about both, that can then, hopefully, translate into policies that help improve quality and reduce costs.
Fred- it’s good to hear from HAWAII. I’m jealous of you already as I stare out the window today at the rain. Maybe I can take a field trip out to visit you sometime!
And Maryann - thanks for your thoughts. On Chiro services, health plans used to make decisions about medical necessity, which, as you point out, is a good way to use this kind of benefit. People hated having the plans decide what was medically necessary, so we decided, instead, to simply include a certain number of visits in as part of the health care benefit, guess (in an educated way) about how many people would use them, and then put that cost into the price of the insurance people purchased. It’s clunky, I know, but it keeps us - on this issue - out of making the medical necessity call - which seems to be the way most people want this to work.
Re “narrow network” plans — do you think they’ll fly this time around? It’s an idea that has been around before . . . The Any Willing Provider proselytes haven’t gummed this up yet, but don’t you think they might once HPHC and/or the other insurers offer plans that cut them out?
– David Harlow
Phewww!
With the flurry of activity around what seems to be the last of the important design decisions the Connector has to make, this HPHC blog may take a while to get airborne, but I think Mr. Baker is pushing us down the runway as hard as he can.
His point about the fact that AFFORDABILITY hasn’t been addressed is telling. Of course he is right that Chapter 58 really doesn’t address this. I would add two things:
1) Jon Kingsdale was explicit early on that affordability would not be addressed. While I would have preferred dealing with affordability first, the political will necessary to lift Chapter 58 to its heights was directed at “access”, so that’s the piece we’re doing first.
2) If health care cost inflation cannot be brought down to the level of general inflation, Chapter 58’s success will be short lived. The state could throw more money at it (witness the compromise voted by the Connector just yesterday, adding $13 million more state dollars to subsidize those between 100-300% of the Federal Poverty Level) but this would only be a short term solution.
I think that long term solutions to the affordability problem involve changes in American cultural values. Our perceptions of all the following must be re-examined and changed:
…. What is health?
…. What should health care (not “insurance”) do for us?
…. What should health insurance (the time-compressed value
of the cost for health care) pay for?
…. What is the responsibility that each person has for his own
health (preventable accidents/illnesses)?
The value-laden answers to these questions will allow us to define and confront our own mortality and morbidity and lead us to EXPLICITLY ration the limited resources we have to pay for our health care.
One of my favorite Winston Churchill quotations is his observation that “Americans always do the RIGHT thing. –After they have exhausted all the alternatives.” Chapter 58 appears to be the RIGHT thing here and now, but I’m not optimistic that it will work in environments as different as California or Texas. And that’s just fine, so long as we don’t give up trying the NEXT alternative.
Ed - Believe it or not, I’ve proposed something similar in the past. I’ve often wondered what the health care system in this country would look like if Medicare and/or Medicaid had been conceived as reinsurers (like Freddie Mac and Fannie Mae for home mortgages) instead of as primary insurers. As primary insurers, both programs drive the system. As reinsurers, their roles would have been different. The notion you propose above - private insurance and multiple options with a publicly funded reinsurance model - would have been, in my opinion, a much better answer than the one we’ve got.
Gerry, your comment about the fact that most health care reform discussion is about care delivery, finance, insurance - almost everything but an honest and sophisticated reflection on the end user, the consumer - is absolutely right. The system will not get better if people think it’s all about the “system” - and not about the people who use it.
David, check out my latest comment on the “Drugs…” blog I put up at the end of last week. It refers specifically to narrow network products - and whether or not now might be a better time for the reintroduction of these kinds of products. Thanks.
Charlie,
Thank you for hosting the broker/consultant breakfast yesterday.
I have two items for your staff and you:
1. Chapter 32B/Section 19 and the GIC Legislation: I have come to the conclusion that we should support this legislation simply due to the fact that it does give municipalities one more cost control option to consider.
However, has anyone completed an actuarial study to confirm that the PMPM claims utilization for a state employee or retiree is lower than the same for a given municipality? If it is not lower, what are we really doing here?
I contacted the Metropolitan Mayor’s Association, Bob Johnson at the GIC and Senator Moore and so far no one has produced an actuarial study.
I am confident that the GIC rates are lower only due to two simple factors; the GIC has unilaterally increased the plan design copays over the past few years and they have tiered provider networking.
I am not convinced that the GIC can document so called “clought” or “buying power”. Fallon has confirmed that their premium rate calculation for the GIC is the standard rate calculation they use for all other municipalities. It is also my understanding that the HPHC retention rate is standard based on the GIC group size. Where is the buying power?
Recognizing HPHC offers plans to both the GIC and Boston, does HPHC have an actuarial study or any other analysis that may assist us?
2. Health Care Reform - Based on everything I have learned to date, I don’t believe the new law will impact MA municipalities to any great extent, assuming they have a Section 125 plan.
However, I do not know the impact to MA municipal employees currently working less than 20 hours and not insured elsewhere. Assuming such an employee wants to but a plan through the Connector, what must the MA municiplaity do? Allow payroll deduction and make the monthly payment to the Connector? Logistically how will this work?
Your feedback is appreciated.
Kevin