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发帖数: 29846 | 1 High Rates of Serious Medical Conditions in New Plans Put Pressure on
Premiums
June 24, 2014 8:34 p.m. ET
People enrolled in new plans under the health law are showing higher rates
of serious health conditions than other insurance customers, putting
pressure on insurers around the country as they prepare to propose rates for
next year. WSJ's Christopher Weaver joins Simon Constable on The News Hub
to discuss. Photo: Getty
People enrolled in new plans under the health law are showing higher rates
of serious health conditions than other insurance customers, according to an
early analysis of medical claims, putting pressure on insurers around the
country as they prepare to propose rates for next year.
Among those health-law marketplace enrollees who have seen a doctor or other
health-care provider in the first quarter of this year, around 27% have
significant health issues such as diabetes, psychiatric conditions, asthma,
heart problems or cancer, the data show. That is sharply higher than the
rate of 16% for last year's individual-consumer market over the same time
frame, according to the data, which was supplied by Inovalon Inc., a health-
technology firm that receives medical claims directly from nearly 200
insurers that are its clients.
It is also more than double the rate among people who held on to their
existing individual policies; among those enrollees, the rate was 12%. Those
consumers, who kept so-called grandfathered individual plans, are showing
by far the lowest rates of use for health-care services such as emergency-
room visits, hospital stays and prescriptions.
The findings provide the clearest picture so far of the health status of
those who bought plans under the Affordable Care Act, and show a sharply
bifurcated consumer insurance market—with sicker, and costlier, people in
health-law plans and healthier people sticking with previous coverage.
Insurers say that dynamic could drive up premiums for many health-law plans
next year, because the Obama administration recently announced that it would
allow the grandfathered coverage to linger into 2016, if states and
insurers choose.
The upshot, in some places, is "a parallel market where the healthier people
stay in the transitional plans," said Cliff Gold, chief operating officer
of CoOportunity Health, a health-insurance startup serving Iowa and Nebraska
. He said CoOportunity Health is proposing to raise rates by an average of
14.3% for health law plans in Iowa, with nearly half of the boost tied to
the effect of people holding on to older coverage from other insurers.
Inovalon uses insurers' claims data to identify patients with health
conditions and help manage their care under contract with the health plans.
The data for the health-law analysis drew on claims that were paid out in
the first quarter, from health plans based in 16 states spread around the
country. Those aggregated claims, from the firm's research database, cover 6
.6 million people for 2014, including about 458,000 exchange-plan consumers,
800,000 with health-law coverage that wasn't bought through a government
marketplace, and 1.1 million who remained in grandfathered plans. Most of
the rest are in large employer-sponsored coverage.
The claims don't include people who signed up for plans in the final weeks
of the enrollment period, which stretched into April. Insurers have said
they received younger—and possibly healthier—enrollees late in the
enrollment period. Because insurance markets are different in each state,
some parts of the country may prove to have healthier enrollees under the
law than others.
Inovalon tallies health conditions identified by federal regulators as
increasing insurers' costs, such as diabetes. For insurers that are offering
health-law plans, such counts carry a vital financial interest, as they
will be a basis for some payouts set up under the law to reduce the
financial risk of covering unhealthy people.
The rate of documented health conditions is "a good leading indicator of
where medical costs are going," said Dan Rizzo, Inovalon's chief innovation
officer. Though insurers don't yet have a complete picture of enrollees'
health, Mr. Rizzo said the firm believed the 16 states provide a "
representative mix of the experience of health plans" nationally.
What impact the health of consumers will have on next year's rates depends
in part on how accurately health insurers foresaw their costs when they set
rates for this year. Some insurers, such as WellPoint Inc., WLP +0.73%
have said that initial signals have shown that their health-law enrollees
appear to roughly match projections.
A spokesman for the Centers for Medicare and Medicaid Services said the
health law includes protections for insurers that enroll unhealthy people,
and more insurers are seeking to sell marketplace plans next year, "creating
increased competition and providing consumers with even more affordable
coverage options."
Still, some insurers say enrollees so far appear less healthy than they had
projected. "It's even worse than what we thought," said Patrick Getzen,
chief actuary for Blue Cross & Blue Shield of North Carolina. "We're seeing
more chronic conditions than we would have expected," he said, and that will
"put pressure on the 2015 rates." Among them are diabetes, depression,
asthma, heart disease and cancer, he said.
People in many health-law plans are likely to be less healthy on average
than traditional individual health-coverage consumers because of the law's
requirement that insurers can no longer charge people more, or refuse to
cover them, based on their health history. Some early enrollees were people
who had been unable to obtain insurance previously because of pre-existing
conditions.
Jo Cooper, 62, who has hepatitis C, said individual insurance was always
unaffordable before the health law took effect. But in December, the
Washington, D.C., resident signed up for a "bronze" marketplace plan from
CareFirst BlueCross BlueShield, which serves Maryland, the District of
Columbia and portions of Virginia. As a result, Ms. Cooper was able to give
up a job with health benefits and work full-time for her own Web-design and
marketing business. "I was kind of stuck" until the health law's changes,
she said.
CareFirst's chief executive, Chet Burrell, says the insurer is seeing many
early enrollees with health conditions who are "beginning coverage, quite
evidently, because they need it."
Marketplace enrollees appear less healthy than CareFirst had reflected in
its rates for this year; it is now seeking an average 25% rate increase for
its Maryland exchange plans, Mr. Burrell said. "Over a period of time, the
rates have to go up to catch up with the reality of who enrolled."
Most Americans with private coverage are enrolled in large group health
plans, such as those sponsored by big employers, that aren't affected by
many of the law's changes.
About eight million people picked exchange plans—including those sold
through the federal HealthCare.gov and state-run exchanges in 14 states—by
April 19, according to data released by the Obama administration.
But many healthier consumers didn't want to give up their old 2013
individual plans, many of which were priced to reflect their lower expected
costs. Facing an outcry, the Obama administration announced last fall—after
insurers had set rates for the coming year—that it would allow the old
plans to be continued if states and insurers opted to do so. Last year most
states authorized such "grandfathering," according to a tally by America's
Health Insurance Plans, the industry's trade group. About half of states
will let old plans persist at least into 2015.
The people in pre-health-law plans are overall "a lot healthier," and the
effect is "going to be a major issue for some states and some health plans,"
says Ross Winkelman, an actuary at Wakely Consulting Group, which is using
data from 51 insurers in 33 states to analyze the health status of enrollees
. Keeping these healthier people out of the new plans could increase average
per-member medical costs for some health-law plans by "double digits" in
percentage terms, he said.
MDwise, a nonprofit health insurer in Indiana, has proposed an approximately
25% rate increase for 2015. Chief Executive Charlotte MacBeth said "a big
portion" of the increase was tied to the effect of people keeping old plans.
MDwise, which mostly focuses on Medicaid, didn't sell individual plans
before this year.
The full impact of the continued grandfathering will play out in coming
months, as insurers' rates for next year become public. Overall, rate
filings from the handful of states that already have released them show a
mixed picture. The wide variance is driven by many factors, including
insurers that are trying to boost enrollment with low prices. Also, premium
increases are being damped by the law's financial protections for insurers,
industry executives say.
An analysis of filings from 11 states by Sector & Sovereign Research LLC
found the average increases by state ranged from 1.2% to 21.8%. Weighted by
enrollment, the average among them was 10%.
Inovalon's data show the new health-law enrollees, despite their relatively
high rate of documented health conditions, weren't yet using pricey services
at the fastest clip. They were less likely to have seen health-care
providers than those with employer plans, for instance. Mr. Rizzo said newly
insured patients may not have existing doctor relationships. Another likely
reason, industry executives said, could be the big deductibles in many
health-law plans. | m********8
发帖数: 7463 | 2 wasn't that the whole point? 你们地富反坏右太狠了
扶贫济弱难道不是天朝上国应该做的事情么 |
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