Phil Hauck's TEC Blog

Sunday, February 28, 2010

Thoughts On the ObamaCare Plan Problems

Why does Congress think that the solution to the health care dilemma lies in insurance pressures.
It is not the responsibility nor mission of a sickness insurance company to provide for the U.S. population. As private enterprises, their job is to carefully judge the next year's risk profile (likelihood of needing care, and for how much cost) of a prospective customer ... and to put a price on it based on the going rates in that community. The prospect can accept or reject. If many people have high risk profiles, as many of us increasingly do, and the going rate/cost is more than we can afford, then they go without. Don't blame the insurance companies.

Right now, we have too many people with high risk profiles (30%-40% of us are obese, for instance, with all that brings along with it ... asthma, diabetes, cancer, joint repair and replacement, etc.) and a too high "going rate" ... driving the premium costs very, very high. (Of interest, our Healthy Lifestyles Co-op just went through our three-year re-ratings of members, and the new premiums came in very, very high; indeed, we know of at least five companies who will now go without insurance.)

So, how do we "provide" for those who can't afford private insurance? Not what Congress is doing.

Here's what Congress is trying to do: Effectively, give everyone access to sick care ... with service coverage for what they can't afford provided by the "larger entity" ... the "larger entity" being an insurance company if they can afford it, or if they can't afford it, a "public option" that will be funded by the American people or Medicare funded by the American people. (Note: There is no Congressional requirement that any of us pursue a lifestyle that will do much to keep us away from needing the system, and as many of us know, when something that we want is free, we use lots of it. Why not? Think open bars.)

Congress would theoretically force cost savings by cutting the Medicare reimbursements to providers (even for prescriptions?). Right now, the provider system isn't efficient or effective enough to operate at current Medicare reimbursement levels ... and cutting them further just might force some cathartic reorganization of how sick care is delivered (we're still ignoring incenting people to healthier lifestyles). (And Congress doesn't have a great track record of rebelling against lobbyists and actually cutting the income levels of a huge industry. Where are the unions?) Actually, that cathartic reorganization might probably happen, which might be very good.

In the meantime, we will have what other countries have: We will have more people trying to access the same number of doctors/providers, so waiting times will go up. We will probably have fewer people wanting to be doctors given the cost of education/skill development and lesser income levels, exacerbating the access challenge. We will need to think about funding grants for health care professional education. Under Medicare cash controls, the ROI for developing new medicines and diagnostic equipment will be lower, reducing the incentive and investment levels for medical advances. You've read about other implications as well.

As we know, when government tries to keep up with advances so as to adjust its regulations and other controls, it's always behind the times as well as being conflicted when change is happening at a high rate.

All of the above is to explain in a different way, perhaps, why government control won't work ... why the current effort should be defeated and why Congress should immediately think through what the ideal system would look like, and enable it. What will work is for Congress to determine what the best structure of the key elements would be, and then to enable them with regulations, incentives and penalties.

Changing Role of Health Insurance Agents

Traditionally, the role of the insurance agent for most smaller companies has been to scour the marketplace annually or every other year for a cheaper deal, including plan changes that lower the cost. For this, the agent is paid a commission ...ranging from 1%-3% for larger companies, to about 5% for smaller companies ... and sometimes significantly higher than that the first year.
However, there is a likelihood that the agent's role will increasingly morph to being a consultant on a wider range of programs that can mitigate insurance costs ... and to get paid a fee for providing that consulting. Right now, companies want advice on how to cost effectively approach the Wellness/Fitness programs that can create better health and productivity. Much of what companies currently do is sold to them by the providers, and is cost in-effective or at least not cost-justified. They need an expert who can sort the productive from the non. Agents will have to figure out how to price this additional role.
Another influence will be federal/public pressure to continue to reduce the product distribution costs inherent in an insurance company's administrative costs. Currently, the biggest element is that 5% commission charge. There will be pressure to reduce it.

Ideas from the Feb. 4 Champs Meeting:

• Find a long blank wall, and for each person, put "footprints" for each day the person achieves the 5,000 step level. When 75 are completed by Sept. 30, the wall is full. It will show who's doing it and who isn't ... social pressure!
• Post the Challenge of the Day on the bulletin board.
• Provide fruit all day at 25 cents per apple or banana.
• Meet individually with each employee to discuss the program, objectives, and personal problems in achieving it. Will create comfort and better interactions in the future around program challenges.
• Bring in Jane Birr for a program every two weeks on the Monday.
• Use the Bellin nurse program for a Healthy Loser weight loss contest. Small rewards for winners.

What if ...

Personal tax rates for all U.S. citizens were raised each year to pay for whatever the U.S. Budget's projected deficit is for that year.
That way, politicians know that their spending plan will directly impact their constituents personal income ... and the constituents know it, too!

Health Care is NOT a RIGHT!

It is a BENEFIT, but only as long as we can afford it.

Saturday, February 27, 2010

Insights at WMC's Madison Day, Feb. 23

Along with several others from Green Bay's Chamber membership, I attended the annual Madison Day event sponsored by the state Chamber, Wisconsin Manufacturers & Commerce. The speakers included four people from Washington, DC, with commentary on events transpiring there, and a panel on the health care cost dilemma. Following are some of the highlights that I brought back for you:

John Torinus, CEO of Serigraph, a 1000-employee West Bend printer and conservative Journal Sentinel columnist:
• “We have to bust the health care business model. The current one is busting every company’s budget, every government’s budget, the national budget, every school system’s. A just talked to an insurance consultant with 300 company clients. His 2010 insurance premium increases are in the 15%-25% range. Totally unsustainable.”
• “I don’t care about what’s transpiring in Washington or Madison because it doesn’t sufficiently affect me in a positive, solution-oriented way. Here’s what has to happen ...”
• I. Every American has to be engaged, fully engaged in their own health maintenance and sick care treatment. We have to stop removing them from the payment and responsibility process. That requires massive behavior change, and it all starts with their pocketbook. Every family needs to have a Health Savings Account with a high deductible plan. Their insurance can’t start paying for their care until well past normal year-to-year challenges of a healthy person.
• II. Put Primary Care back in a Primary Role. Use the Quadraphics model, whose cost of care is 40% below the Milwaukee norm. One key is Chronic Disease management, coordinated by an incented Primary Care physician. At Serigraph, we’ve hired a Concierge Primary Care Doc for our workforce. He helps with second opinions, runs interference where the patient doesn’t understand, is the primary care doc for those who don’t have one, deals with HIPAA-protected counseling.
• III. Use Centers of Value. Prices are chaotic, unrelated to market or quality. Know what the big costs are, and incent your people to go to the lower cost places that are known to have good quality ratings (accessible, low infection rates, etc.). We pay an employee $2000 to go to the provider with $15,000 hip replacements, avoiding the more expensive ones.
• When you consider that governments are averaging $15,000-$16,000 per family in costs, whereas the average is $12,000 and some companies like ours average $8,000, why isn’t there movement??? An automatic to begin the leap is to require high deductible HSAs, to begin engaging the employee in the decision-making process.
• Progress: The WHIO Health Analytics Exchange will bring better process to the provider marketplace.
• Transparency could be required at any time via Executive Order. Why isn’t it?

Another speaker was Dee Dee Myers, President Clinton’s press secretary, who had a number of interesting observations, including some funny ones:
• Washington, DC: A Work-Free Drug Zone.
• The Mayor’s 2010 Snow Removal Program: Spring.
• A man was drowning in the Potomac, and two people, a Republican and a Democrat, rushed to his rescue. The Republican threw him 50’ of rope, and said “The rest is up to you!” The Democrat threw him 200’ of rope, and then released the other end into the river.

• What has caused the current malaise of Partisanship:
Gerrymandering, where politics was used to make voting districts controversy-free ... either predominantly Democratic or predominantly Republican. As a result, an elected legislator has to appeal to a radical left or right electorate to get funded and re-elected. There is no virtue in the center or in collaboration.
The speed of media/communications technology, coupled with news media competition putting a premium on controversy. (“The problem is US. We care more about what’s compelling, not what’s truly newsworthy.”)
President Obama’s poor linkage between talking about the generalities of decisions, and actually making them. This is coupled with tackling too many big issues at one time, too little job security throughout the nation, and releasing too much control of the agenda to a dysfunctional congress.

Another speaker was Charlie Cook, a noted Washington-based political analyst. Among his comments and insights:
• “It ook Republicans 8 years to destroy their brand. It took Democrats just one year to do it.”
• Purple America is now dominant. Independents are 36% of the electorate, Democrats are about 34% and Republicans about 30%.

Tom Barrett, Milwaukee mayor and Democratic candidate for Governor: “People don’t care whether the person who picks up their garbage is a Republican or a Democrat, nor whether the person who removes their snow is a Liberal or a Conservative.”

"Everyone Can Agree On"? No Way!

The latest Washington proposals to enact the several things that "everyone can agree on" keep talking about giving smaller businesses the opportunity to combine into pools so they can both use the power of the pool to (1) make health insurance less expensive for less healthy groups and (2) provide higher volume for leverage in getting better deals with insurers and providers.
The problem is, this won't work ... and it's been proven time and again, most recently by our own Healthy Lifestyles Co-op of Brown County. No healthy group will stay a part of a group where it is subsidizing less healthy ones. Result: Adverse selection as other insurors pick up the healthy groups with lower prices.
Everyone knows this, I think, so why do the Washington negotiators even bring it up? (Help me to understand this. What am I missing after years of involvement in trying?)
PS: Our Co-op didn't yield better rates because our very real fitness gains were offset by non-participants whose prognosis for sick care expenses increased. Houston: "We have a COST problem, NOT an INSURANCE problem!"

Another observation, about the "everyone can agree" that people with PRE-EXISTING CONDITIONS should be automatically accepted by insurors, and can't reject services as "not covered". What kind of a business model is that for any privately-held organization? Help me: I'm required to take on a "customer" who will pay me $6,000 but I know will cost me $25,000?
This MIGHT work if everyone is required to buy insurance (about which there is far from agreement), but even if that's done, any insuror could get a disproportionate amount of expensive pre-existing condition people that could financially ruin it.
(Yes, there are ways to deal with this as a nation that would actually reduce total costs AND include people with major pre-existing conditions ... but these models definitely aren't being discussed in Washington. Nothing that would reduce costs is.)

For ideas about what "everyone can agree on" (other than industry lobbyists), see my blog below.
They are:
• Transparency of pricing.
• Reduction of Medical Liability exposure.
• An emphasis on Fitness and Wellness.

Economic Forecasting Limitations

By Russ Roberts, Hoover Institution economics expert in 2/27/10 WSJ:
Economists have learned some things that have stood the test of time and that we almost all agree on --- the general connection between the money supply and inflation, for example. But the arsenal of the modern econometrician is vastly overrated as a diviner of truth. Nearly all economists accept the fundamental principles of microeconomics -- that incentives matter, that trade creates prosperity --- even if we disagree on the implications for public policy. But the business cycle and the ability to steer the economy out of recession may be beyond us.

More great insights from Warren Buffet

Here is Warren Buffet's annual shareholder's letter. It has great insights and philosophies for us all on pages 3-22, and on pages 89-94.

Monday, February 22, 2010

Job Creation Stimuli from a Business Owner Viewpoint!

Both state and federal government officials are developing plans to spur job creation given the current economic doldrums, and we hear what the politicians ideas are. But what do business owners, who actually create the new jobs, feel would help them expand?
Following is a list of ideas provided by about 20 Green Bay area CEOs, members of TEC CEO groups, that they feel would help them.

1. Keep as much money in people’s pockets as possible so that they can buy ... and provide an environment that stimulates them to buy. Don’t take our markets away! When people feel that tomorrow will be better than today, when the uncertainty about tomorrow is replaced by confidence, they will begin buying more goods made by our companies. (Consumers drive about 60% of the economy; capital expenditures (see #3, below) drives the rest.)

2. Eliminate all business taxes except usage taxes. The business is the “golden goose” whose efforts eventually create jobs. Taxes on businesses take dollars away that could be spent on job-creating efforts. The business of a business is to fulfill a customer need/want. They should not be impeded unnecessarily in doing that. Taxes should be paid by people, not job-creating enterprises. (This includes taxing of inter-state services.) Dollars not used for taxes can be used for R&D, new product development, seeking new customers, increasing manufacturing capability ... and hiring new workers!

3. Re-institute Accelerated Depreciation, which will incent capital expenditures which fund capacity expansion which drives down prices. The Institute for Policy Innovation estimates every $1 of depreciation deductions generates $9 of output growth.

4. Insure a supply of trained workers ... by providing grants for training/re-training, or funding technical schools to do that training/re-training.

5. Invest in new infrastructure ... infrastructure that is key to tomorrow’s competitiveness (broadband, etc.).

6. Reduce the costs of Regulation. Regulation is important ... it assures minimum standards. Regulation should be cost-justified against the benefits. Example: Eliminate multi-state duplication of licenses.

7. Corollary: Reduce/Don’t Increase the administrative and tax costs of having an employee. This is why it’s important to control rises in Health Insurance, Social Security, Medicare, and other societal benefits.

8. Corollary: Increase/Don’t Reduce the incentive to work. Insure it’s not more beneficial to collect Unemployment Compensation than to work for available wages. Keep a large differential between them.

9. Don’t play favorites. Keep the playing field level.

10. Provide grants to incent basic research which might lead to development of patentable, commercializable ideas.

11. Stop creating uncertainty around interest rates, availability of capital, and costs of employing workers. This uncertainty results in postponed expansion efforts. Control interest rates at low levels and without volatility to reduce barriers to capital investment borrowing.

12. Foster globalization. Don’t impede it. All economics is about Comparative Advantage. Let everyone do what they do best, and let the buyer/user judge whether to buy/use or not. Many of America’s jobs depend on export business.

-- Phil Hauck is chair of three local TEC CEO Groups.

Three Health Care Legislation Suggestions for Congress

Now that the Democratic health insurance initiatives have been neutralized, it still remains for Congress to make some progress in abating the rising costs of sick care that has taken 10% more of family income in the last 25 years, and continues to take more and more.
Some of the requirements being discussed are just plain silly. Consider these:
• As important as it is, requiring insurors to accept everyone regardless of pre-existing conditions is tantamount to bankrupting them. How can they be required to blindly take on an expense stream that is funded by much less than it costs?
• How can we “pay for” the added costs of the uninsured by reducing the Medicare expenses of our senior citizens, when the Medicare reimbursement is already below the providers’ costs. Already, the Mayo clinic in Arizona is declining Medicare patients. (Yes, it might work if the system became more efficient and less costly.)
Right now, the main driver of high costs is the fact that Americans over more than a generation have eaten too much and exercised too little, creating bodies that are incubating very expensive diseases. That works when there are few of them relative to those who can pay but don’t need the treatment, but now there are too many of them (and more and more) requiring more dollars of treatment than healthier people can afford to pay out on their behalf. That’s why we have this crisis.
Given that, here are a few steps that Congress could take fairly quickly and easily, and for which there will be Democratic, Republican and constituent support (although not from several influential lobbying groups):

1. Wellness/Fitness Involvement: Send the message that Americans have to maintain healthier lifestyles that don’t require as much expensive sick care as we do now. Do it by requiring everyone to have an annual Health Risk Assessment, and fund a case manager for everyone scoring below 60% and/or having multiple risk factors. Also, give employers a better chance to successfully incent participation in both wellness and fitness activities by expanding the legal incentive spread between participating and non-participating employees to 50% from the current legal maximum of 20%. That has been recommended to Congress. If the first seems too difficult, at least do the second.
2. Transparency and Education: Require providers to publish the most common ranges of costs for each service at the point of service so the consumer knows in advance. Also, have consumers provided with a list of questions to ask depending on the symptoms found by the doctor. Those two elements will relieve the anxiety of the consumer: They don’t know the questions to ask, and feel embarrassed to ask about cost so they can make a price/value decision. Insurors and providers will argue that the prices vary depending on the discount. This knowledge will move the market towards the lower part of the range, and drive it even lower.
3. Medical Liability: Congress doesn’t discuss it because lobbyists don’t want it discussed. The cost of liability premiums is about $2 billion a year, and drives an estimated $210 billion (of the $2.4 trillion national health care expense) in unnecessary tests, experts estimate. Provide caps for punitive damages, and limit payouts to the costs of treatment and maintenance.