Managed Care - February 2008 - (Page 18) LEGISLATION & REGULATION try that has seen expenses in the region rise 8 percent to 12 percent each year for more than a decade. There’s a catch Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, which is charged with expanding coverage, told the New York Times that he thinks Massachusetts can get its uninsured rate down to the single digits. But there is a catch on costs. If health care costs continue to go up steadily and steeply— premiums in Massachusetts have risen at about 10 percent a year — all bets are off. “If we continue with double-digit inflation,” said Kingsdale, “I don’t think health care reform is sustainable.” The connector had some suggestions for ways that plans could rein in premium increases. At the top of the list: Steering patients to low cost, high quality providers, offering disease management programs to help control costs for the most expensive patients, and urging generic drugs whenever it’s appropriate. But health plans say there’s no reason to believe that MCOs can suddenly expect any one or all of those strategies to suddenly deliver dramatic, overnight savings. Disease management and generic drug preference have been in play for years, says Buyse, while ranking high-efficiency physicians has been fraught with difficulty. In Massachusetts, where there is a widespread shortage of primary care doctors, trying to steer patients is no easy task, Buyse adds. Caught in the headlights of the oncoming reform initiative, Tufts Health Plan and Harvard Pilgrim have called for public hearings so that people can gain a clear understanding of the formula used to calculate premiums in the state. But if you want to control premiums under a mandate, says Buyse and others in managed care, providers have to be willing to sacrifice any significant gains they may have in mind. “You can’t be a hospital and ask for a doubledigit increase when plans are being held to 5 percent,” says Buyse. There’s been a considerable amount of math done calculating the impact of universal coverage plans, and none of it adds up to 100 percent coverage. The Urban Institute analyzed the Massachusetts reform effort and concluded that if it expanded Medicaid to include more people and provided subsidies to families up to 400 percent of the poverty line, the state could get about half of the uninsured into a plan. It takes a mandate with both easy enrollment provisions and effective enforcement mechanisms, according to the institute, to approach universal coverage. And even in Massachusetts, more than 1 in 10 of the uninsured are exempt from the requirement because they still can’t afford coverage. Once you factor in illegal immigrants and hard-core resisters who won’t buy health insurance regardless of subsidies, no state can expect to reach full coverage. You never get 100% “Let’s be realistic,” says John Holahan, a health care analyst at the Urban Institute. “You never get 100 percent of anything.” But there are some definite pluses for the managed care industry, he adds, particularly if you consider that many of the people signing up for insurance will include the lower risk, younger population that has been taking its chances going uninsured. “Covering the uninsured,” says Holahan, “you’re going to have more covered lives. A mandate brings in younger, healthier types, so you bring in good risks.” “We feel very strongly that working families need a helping hand,” says Karen Ignagni, the CEO of America’s Health Insurance Plans. Ignagni is quick to point out that the industry association isn’t endorsing any of the candidate’s plans, but “we agree with proposals for repairing the safety net. That’s important.” Whoever is elected this fall, says Ignagni, AHIP will be ready to leap into the discussion with the new president. Unlike the debate over the Clinton plan 15 years ago, she says, the managed care industry now has a plan of its own. “Our industry is very different than in ’92,” says Ignagni. “In ’92 we were reacting, now we’re proposing.” MC 18 MANAGED CARE / FEBRUARY 2008
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