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AHIP meeting: Wizards of R's

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Four thousand actual and would-be health care system movers and shakers are converging on Nashville this week for the America’s Health Insurance Plans (AHIP) Institute 2015 annual meeting.

AHIP goes into the meeting conference with Daniel Durham, a former executive vice president for policy and regulatory affairs at the Pharmaceutical Research and Manufacturers of America (PhRMA), serving as acting chief executive officer, and AHIP members facing about as much upheaval as they’ve been facing almost every June for the past 20 years.

Preshow forums start today, and former President Bill Clinton is supposed to close the show Friday.

Major event vendor sponsors are trying to get the insurers to focus on offering better health coverage, and health care management services, more efficiently, with better customer service.

Benefitfocus is urging insurers to think beyond private exchanges. HGS Colibrium Inc. is unveiling a health insurance customer relationship (CRM) management system.

Benaissance and hCentive are promising to help straighten out health insurers’ billing processes.

Softheon is offering public and private exchange survival advice, Halfpenny Technologies and TMG Health are two of the dozens of companies talking about tools for improving population health management.

Analytics Partners and competitors are demonstrating systems that can help insurers shift to the ICD-10 diagnostic code standard.

Clinton and former presidential candidate Mitt Romney are getting ready to go on as speakers. 

But the insurance company executives, vendor representatives, consultants, brokers and other attendees in the seats are about as uncertain this year as they’ve been at just about every other AHIP Institute event for the past 20 years.

In the mid-1990s, carriers were waking up from the dream that health maintenance organizations (HMOs), and paying providers one flat capitated fee per patient per month, would fix everything.

In the early 2000s, insurers knew major federal health reform legislation was coming.

Since 2010, insurers have wondered how the Patient Protection and Affordable Care Act of 2010 (PPACA) would work.

Today, insurers wonder… how PPACA will work. They have about as much understanding of what the next year holds as Dorothy did in the Wizard of Oz, after the tornado whirled her out of Kansas.

See also: Health insurance story of the year: The shoe that dropped

For a look at the lions, tigers and bears facing health insurers now, read on. 

Supreme Court justices

1. King vs. Burwell could do anything. 

Maybe a ruling against the ability of the Obama administration to offer the advance premium tax credit (APTC) subsidy in states with public exchanges set up by the U.S. Department of Health and Human Services (HHS) would just wipe out the individual exchange plan market in a few states with HHS exchanges and fragile insurers.

Maybe it could somehow destabilize both on-exchange and off-exchange individual markets throughout the country.

Make it could even destabilize the small-group market, or the large-group market, or turn into a giant lizard and fly around the country eating cars.

No one really knows.

See also: Rick Perry: Congress should repeal PPACA, but let the states replace it and Scott Walker: Congress should step in if Supreme Court erases PPACA subsidies


2. The pharmaceutical companies could develop a drug that makes everything completely perfect. For $500,000 per year.

Just before AHIP started its meeting, the American Society of Clinical Oncology held a meeting of its own.

The oncologists there were talking about the possibility that some specialty drugs could soon cost $200,000 per patient per year, that a number of drugs already cost more than $100,000 per year, and that there’s talk of a drug cocktail that will cost some patients with advanced melanoma about $295,000 for less than a year of treatment, without actually curing those patients of melanoma.

Dr. Leonard Saltz, a stomach cancer doctor, made a statement that many insurance industry executives would shy away from uttering in public.

Saltz told a Bloomberg reporter: “We need to first accept that there has to be some upper limit as to what we as a society are going to be willing to spend on a patient, and we have to be willing to engage in that discussion. It’s a very uncomfortable discussion.”

See also: This cancer doctor is leading the attack on astronomical drug prices

Skull and cross bones

3. The PPACA “three R’s” risk-management programs could suddenly become interesting to everyone, and easy for everyone to understand, because they crush big, established health insurance companies.

In the past, most previous efforts to have either private or public insurers offer a varied group of consumers a choice of plans without use of medical underwriting, and without use of health-status-based pricing, have failed, because the sicker consumers poured into, and killed, the plan with the richer benefits and more attractive provider directory.

Congress created the risk-management programs — a temporary reinsurance program, to protect individual insurers against enrollees with catastrophic claims; a temporary risk corridors program, to protect issuers of PPACA-compliant qualified health plans (QHPs) against poor operating results; and a permanent risk-adjustment program, to use cash from plans with low-risk enrollees to help plans with high-risk enrollees — in an effort to give insurers the confidence to hold rates low.

Congress also created the three R’s protect the insurers, and the PPACA ban on medical underwriting, from the antiselection forces that have destroyed most earlier efforts to give patients a choice of plans while letting sick patients pay the same rates that healthy patients pay.

HHS has not said much in public about how the three R’s program will really work.

The U.S. Government Accountability Office (GAO) has just reported that HHS has not told insurers much about how the three R’s will work, either or about how insurers are supposed to feed data into the three R’s administration systems.

Several insurers told the GAO that HHS simply stopped answering questions about the three R’s from the fall of 2013 through the spring of 2014, during the first PPACA open enrollment period.

Insurers told the GAO that they still have trouble getting clear information about how to send HHS three R’s data.

See also: PPACA three R’s programs: Insurers cry out


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