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On the Third Hand: Utilization

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I’m starting to try to figure out how to cover how the various new Patient Protection and Affordable Care Act programs affect use of health care, and it hit me that one important point is that it’s important to try to watch all of the claim data balls, not just the bright shiny object consisting of private exchange plan data.

On the one hand, the PPACA health insurance exchange plan “qualified health plans” are fun to follow because they are extremely concrete. They’re a new product.

They’re interesting to anyone into government health programs because government agencies set up them up and in many cases directly run them.

They’re interesting to people into commercial health insurance, because commercial health insurers write the exchange QHP coverage and, in most cases, commercial agents and brokers can sell the exchange QHP coverage, the same way they’d sell disability insurance or travel insurance.

We can collectively holler at various government agencies when they fail to report on what’s going on at the exchange QHPs as quickly or as comprehensively as we would like.

But, on the other hand, even in PPACA World, exchange QHPs are still just a small, weird part of the commercial health insurance market.

Plenty of people will have commercial group or individual coverage written before PPACA took full effect for months, or years, to come.

Even among people with truly PPACA-compliant coverage, it seems as if about half of people are getting QHP coverage — plans almost the same as the exchange QHPs outside the exchange system — and it seems as if plenty of other people may still be getting PPACA-compliant, non-QHP coverage outside the exchange system.

A carrier may be able to avoid exchange-related risk by selling exchange QHP, non-exchange QHP and non-QHP PPACA-compliant coverage all at the same time.

And, after a great deal of companies gouging one anothers’ corporate eyes out in hearing rooms, the new PPACA risk-management programs might be able to compensate any huge claims differences between the exchange QHP, non-exchange QHP, and non-exchange, non-QHP markets.

But, on the third hand: Think of how complicated the previous paragraph was. Maybe having to suddenly think in terms of three parallel markets where one business stream used to exist will create burdensome costs and complications all by itself.

And, on the fourth hand: What if what PPACA has really done, in all three parallel markets, is give providers, patients, carriers and other players new incentives and opportunities to lie to themselves and one another about what’s really going on?

It seems possible that money talks in one stream and something less pleasant may move in three unattractive parallel streams… 

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