PPACA

WASHINGTON (AP) — The next few years could be great for employers that sponsor group health plans but hard on self-employed people and others who buy their own individual or family coverage.

Analysts at PricewaterhouseCoopers’ (PwC’s) Health Research Institute give that assessment in a new study.

The analysts predict that direct medical care costs will increase by 6.5 percent next year. Earlier, the analysts were predicting that costs would go up 7.5 percent.

The cost of care is the biggest component of premiums, followed by administrative expenses and overhead.

“There are some underlying changes to the system that are having an impact, and we can expect lower increases as we come out of the recession,” said Mike Thompson of the PwC institute.

Cost “is still going up, but not as much as it used to,” Thompson said.

PwC analysts said the following factors might help to hold costs down in 2014:

  • Patients seeking more affordable routine services in settings like clinics springing up in retail stores, as opposed to a doctor’s office or the emergency room.
  • Major employers contracting directly with hospital systems that have a proven record for complicated procedures such as heart surgery and certain back operations.
  • The government ramping up penalties on hospitals that have too many patients coming back with problems soon after being discharged.
  • Employers’ ongoing effort to shift more costs to workers through higher annual deductibles, the amount people must pay each year before insurance picks up. 

Factors that could push health care costs up include the high cost of specialty drugs, such as drugs for cancer, and health care provider consolidation.

One downside of the demand for greater efficiency by employers and government is that it may be fostering new health care monopolies, the PwC analysts said.

For healthy buyers of individual policies, the analysts suggested, the challenge may be that the cost of changes in individual market rules will offset the effects of cooling health care cost inflation.

Today, 160 million Americans get their coverage from employer plans. Fewer than 20 million Americans buy individual or family coverage on their own.

But Patient Protection and Affordable Care Act (PPACA) changes could lead more people to buy individual coverage in coming years, and some PPACA provisions — such as the provisions that require insurers to accept patients with expensive pre-existing medical problems, without imposing pre-existing condition coverage exclusions — could make individual coverage more expensive, the PwC analysts said.

The new rules might help expand coverage access for people who now have difficulty buying coverage but raise premiums for people who are healthy enough to get coverage under the rules now in place.

PPACA calls for the government to provide new tax credits to help people with incomes between 133 percent and 400 percent of the federal poverty level to afford individual coverage premiums.

Allison Bell added information to this report.

See also: