Defined contribution health care: future direction or fantasy?

Will payers embrace defined contribution plans as an alternative to traditional health insurance or is this new approach a pipe dream? Are consumers truly ready to make informed decisions on purchasing their own health care? This article explores barriers to defined contribution health plans, including consumer reluctance to take ownership of buying insurance and a preference for the cost predictability of liberal coverage in employer-sponsored programs versus MSAs or higher co-payment arrangements. For the ultimate form of defined contribution health care to work, several tax and insurance barriers must be overcome. As a practical matter, the author argues that the current employer-sponsored approach is the most efficient system for large employers.     

MANAGED COMPETITION IN HEALTH INSURANCE

Rising healthcare costs have sparked debate about the best way to provide high‐quality affordable health insurance. We discuss the potential for regulated insurance markets to outperform single‐payer public insurance. We use as an example the private Medicare plans that now provide insurance to almost a third of seniors in the United States. The evidence suggests that private plans can limit costs and potentially appeal to enrollees, and that well‐designed risk adjustment can mitigate market failures due to adverse selection. However, fostering competition between insurers, especially in smaller markets, is difficult. We discuss how future research might illuminate the relative advantages of public and private health insurance.     

Equitable Taxation and the Provision of Health Insurance Subsidies

Current U.S. income tax laws allow many taxpayers to exclude from taxable income part or all of the cost of acquiring health insurance through an employer‐sponsored benefit plan. This favorable tax treatment generally applies regardless of whether the employer or employee actually pays the health insurance premiums. We describe the effects of this tax policy on the U.S. tax system's horizontal and vertical equity. We also explain how taxpayers covered by employer‐sponsored plans are significantly subsidized by the government in acquiring health insurance, whereas taxpayers who acquire health insurance by other means or who are not covered by health insurance at all receive no such government assistance. We conclude that any prospective health‐care policy initiatives, including modifications to the 2010 health‐care reforms, should contemplate both the horizontal and vertical equity of the tax treatment of health insurance premiums.     

Malpractice insurance rates reach boiling point. Physicians burned by lawyers, lawsuits and jury awards

Costs of medical malpractice insurance are soaring. Major insurers are refusing to write policies. And doctors are struggling to pay their premiums. Find out what's behind the insurance crisis.     

Insurer Competition in Health Care Markets

The impact of insurer competition on welfare, negotiated provider prices, and premiums in the U.S. private health care industry is theoretically ambiguous. Reduced competition may increase the premiums charged by insurers and their payments made to hospitals. However, it may also strengthen insurers' bargaining leverage when negotiating with hospitals, thereby generating offsetting cost decreases. To understand and measure this trade‐off, we estimate a model of employer‐insurer and hospital‐insurer bargaining over premiums and reimbursements, household demand for insurance, and individual demand for hospitals using detailed California admissions, claims, and enrollment data. We simulate the removal of both large and small insurers from consumers' choice sets. Although consumer welfare decreases and premiums typically increase, we find that premiums can fall upon the removal of a small insurer if an employer imposes effective premium constraints through negotiations with the remaining insurers. We also document substantial heterogeneity in hospital price adjustments upon the removal of an insurer, with renegotiated price increases and decreases of as much as 10% across markets.     

Insurability and Mitigation of Flood Losses in Private Households in Germany

In Germany, flood insurance is provided by private insurers as a supplement to building or contents insurance. This article presents the results of a survey of insurance companies with regard to eligibility conditions for flood insurance changes after August 2002, when a severe flood caused 1.8 billion euro of insured losses in the Elbe and the Danube catchment areas, and the general role of insurance in flood risk management in Germany. Besides insurance coverage, governmental funding and public donations played an important role in loss compensation after the August 2002 flood. Therefore, this article also analyzes flood loss compensation, risk awareness, and mitigation in insured and uninsured private households. Insured households received loss compensation earlier. They also showed slightly better risk awareness and mitigation strategies. Appropriate incentives should be combined with flood insurance in order to strengthen future private flood loss mitigation. However, there is some evidence that the surveyed insurance companies do little to encourage precautionary measures. To overcome this problem, flood hazards and mitigation strategies should be better communicated to both insurance companies and property owners.     

Price competition,cost and demand disruptions and coordination of a supply chain with one manufacturer and two competing retailers

This paper studies the coordination of a supply chain with one manufacturer and two competing retailers after the production cost of the manufacturer was disrupted. We consider two coordination mechanisms: an all-unit quantity discount and an incremental quantity discount. For each mechanism, we develop the conditions under which the supply chain is coordinated and discuss how the cost disruption may affect the coordination mechanisms. For the all-unit quantity discount scheme, we find that the manufacturer charges the lower-cost retailer for a lower unit wholesale price in order to induce him to order more products. If the costs of two retailers have a remarkable difference, then the all-unit quantity discount scheme cannot coordinate the supply chain with disruptions. While the cost disruption may affect the wholesale prices, order quantities as well as retail prices, it is optimal for the supply chain to keep the original coordination mechanism if the production cost change is sufficiently small. The model is also extended to the case with both cost and demand disruptions. The equilibrium strategies of the retailers are investigated when the manufacturer cannot timely react to the disruptions such that she has to keep the original mechanism. We illustrate the results by numerical examples.     

How should managed care physicians be paid?

When paying a physician for medical or surgical services, most patients expect the traditional bill or charge for that encounter or visit. While most people also pay health insurance premiums, few patients expect to prepay for their health care. But that is the foundation of most managed health care systems-prepaid medicine. PPOs, IPAs, and HMOs are typically health care providers linked together to provide services to a set population for a specific prepaid fee or "capitation" payment. Other providers contract with these managed care insurers to receive a predetermined and often "discounted" professional fee for services. These managed care organizations have already gone through a number of stages in determining how physicians are to be compensated for their services, and further changes loom on the horizon.     

Mandated benefits: a misguided effort

The U.S. Congress is toying with the creation of universally mandated benefits for health care, most specifically in the health care reform proposal offered by the Clinton Administration. The notion of mandated benefits has already become a part of the health care scene in insurance and managed care plans. Instead of benefiting U.S. citizens as a whole, however, mandated benefits are likely to result in a reduction in health care accessibility and quality. The reason is that mandated benefits consume a continuously growing portion of the health care pie. Deming demonstrated that quality brings lower costs, but to obtain quality we must commit adequate resources. The free allocation of resources is negated by mandated benefits.     

Will retiree health benefits survive FAS 106?

Recent months have seen dramatic public announcements about retiree health care coverage. General Motors recorded a $24 billion quarterly loss this year, due almost entirely to a one-time charge for future retiree health care costs. Other major employers have also reported sudden staggering losses, along with plans to decrease or stop retiree health coverage entirely. Some of these companies have been taken to court. The headlines also identify a culprit--an obscure accounting requirement, Financial Accounting Standard 106. To understand how an accounting rule can have such a profound effect on both the health care of our seniors and the financial strength of American industry, it is necessary to understand how employers pay for their retirees' care, how new accounting rules governing these costs can threaten a company's survival, and how employers are changing their employees' health coverage to meet these threats.     

Cost shifting: the final straw in federalization of health care

While cost controls applied by Medicare and indemnity insurance programs initially helped curtail abusive medical billing practices, creative billing techniques have since resulted in runaway medical costs and rising insurance premiums. Employers have been forced to increase employee's contributions to health care by increasing deductibles, copayments, and coinsurance or by simply dropping health care benefits. If National Health Insurance comes to pass, and that is a cry now coming from major employers, it will be followed in time by federalization of all health care delivery systems, including Workers' Compensation. It is the providers who shift their fees into Workers' Compensation, which pays from the first dollar, who will cause the business community to petition Washington for relief. It will claim the need for cost controls in Workers' Compensation to keep American business competitive in world markets.     

Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk

This paper studies regulated health insurance markets known as exchanges, motivated by the increasingly important role they play in both public and private insurance provision. We develop a framework that combines data on health outcomes and insurance plan choices for a population of insured individuals with a model of a competitive insurance exchange to predict outcomes under different exchange designs. We apply this framework to examine the effects of regulations that govern insurers' ability to use health status information in pricing. We investigate the welfare implications of these regulations with an emphasis on two potential sources of inefficiency: (i) adverse selection and (ii) premium reclassification risk. We find substantial adverse selection leading to full unraveling of our simulated exchange, even when age can be priced. While the welfare cost of adverse selection is substantial when health status cannot be priced, that of reclassification risk is five times larger when insurers can price based on some health status information. We investigate several extensions including (i) contract design regulation, (ii) self‐insurance through saving and borrowing, and (iii) insurer risk adjustment transfers.     

Shadow Insurance

Life insurers use reinsurance to move liabilities from regulated and rated companies that sell policies to shadow reinsurers, which are less regulated and unrated off‐balance‐sheet entities within the same insurance group. U.S. life insurance and annuity liabilities ceded to shadow reinsurers grew from $11 billion in 2002 to $364 billion in 2012. Life insurers using shadow insurance, which capture half of the market share, ceded 25 cents of every dollar insured to shadow reinsurers in 2012, up from 2 cents in 2002. By relaxing capital requirements, shadow insurance could reduce the marginal cost of issuing policies and thereby improve retail market efficiency. However, shadow insurance could also reduce risk‐based capital and increase expected loss for the industry. We model and quantify these effects based on publicly available data and plausible assumptions.     

The Impact of Mega‐Catastrophes on Insurers: An Exposure‐Based Analysis of the U.S. Homeowners’ Insurance Market

Insurance is a key risk‐sharing mechanism that protects citizens and governments from the losses caused by natural catastrophes. Given the increase in the frequency and intensity of natural catastrophes over recent years, this article analyzes the performance effects of mega‐catastrophes for U.S. insurance firms using a measure of market expectations. Specifically, we analyze the share price losses of insurance firms in response to catastrophe events to ascertain whether mega‐catastrophes significantly damage the performance of insurers and whether different types of mega‐catastrophes have different impacts. The main message from our analysis is that the impact of mega‐catastrophes on insurers has not been too damaging. While the exact impact of catastrophes depends on the nature of the event and the degree of competition within the relevant insurance market (less competition allows insurers to recoup catastrophe losses through adjustments to premiums), our overall results suggest that U.S. insurance firms can adequately manage the risks and costs of mega‐catastrophes. From a public policy perspective, our results show that insurance provides a robust means of sharing catastrophe losses to help reduce the financial consequences of a catastrophe event.     

Managed care liability.

Debate is heating up concerning proposals that patients have the right to sue their managed care plans for damages from wrongful denial of benefits or delays in care. Some states have recently passed legislation to address this issue and it is expected to be an area of intense legislative debate during this year. As managed care entities increasingly enter the realm of medical decision-making, the additional burden of this responsibility is taking shape. Whether managed care plans should be treated like providers of care and be held accountable for decisions that impact patient outcomes, or be viewed only as insurers is a policy question of immense proportion.     

The Complementary Roles of Mitigation and Insurance in Managing Catastrophic Risks

This paper examines the impact that insurance coupled with specific risk mitigation measures (RMMs) could have on reducing losses from hurricanes and earthquakes as well as improving the solvency position of insurers who provide coverage against these hazards. We first explore why relatively few individuals adopt cost-effective RMMs by reporting on the results of empirical studies and controlled laboratory studies. We then investigate the impact that an RMM has on both the expected losses and those from a worst case scenario in two model cities—Oakland (an earthquake-prone area) and Miami/Dade County (a hurricane-prone area) which were constructed respectively with the assistance of two modeling firms. The paper then explores three programs for forging a meaningful public-private sector partnership: well-enforced building codes, insurance premium reductions linked with long-term loans, and lower deductibles on insurance policies tied to mitigation. We conclude by briefly examining four issues for future research on linking mitigation with insurance.     

A GOAL PROGRAMMING MODEL FOR INSURANCE AGENCY MANAGEMENT

Rapid changes in the business environment have forced property and casualty insurance agencies to re-examine their objectives. The need to maintain contact with a large number of insurers in order to place business, efforts to reduce cost by utilizing company services, and the expanding demand for commercial lines have all had major impacts on these agencies. In this paper, a goal-programming model is developed for use in insurance agency decision-making involving multiple and often conflicting goals. An example is presented.     

CORPORATE RISK MANAGEMENT: A MODEL AND ITS APPLICATION

A problem faced by any corporate risk manager, once he has decided what set of properties will be insured, is to choose among the policies offered by potential insurers. This choice usually involves negotiating with insurers over the exact premium and deductible amounts which will characterize the coverage. In this paper, the problem is modeled in terms of expected utility of different forms of coverage. The model enables a risk manager to select among available terms of coverage and, more significantly, provides guidelines for him in negotiating with the insurers to obtain the best possible terms. As an illustration, an application using real data is described.     

Utilizing Third-Party Inspections for Preventing Major Chemical Accidents

This paper proposes using certified third parties, coupled with Model Risk Management Programs (Model RMPs), to implement EPA's Proposed Rule on the prevention of chemical accidental releases. We concentrate on the insurance aspects of this third-party approach and show that it could enable insurers to more cost-effectively provide coverage against the risks of chemical accidental releases. The third-party approach may also signal the facility's safety and reduce the enforcement costs of regulations.     

Haunts on the Web for physician executives

Listed here are some medical management and health care related Web sites on the Internet worth visiting, as well as favorite search engines and how to use them. From health care systems and hospitals, to health plans and insurers, the industry is using Web technology to promote programs and outcomes, and to provide information on health and wellness.