The consumer-driven approach: defining and measuring success

Employers' reluctance to implement consumer-driven health plans (CDHPs) is at least in part due to their not understanding how to define and measure the success of CDHPs. To assist employers, the authors define potential points of success for CDHPs in the areas of consumer engagement, consumer financial considerations and employee health and productivity. They then offer ways of measuring success in those areas, as well as in the area of employer cost control. By taking a carefully considered approach to the decision of whether to offer a CDHP, employers can grasp potential opportunities to control health care costs.     

Information access: will make or break consumer-driven health plans

Consumer-driven health plans offer employers potentially significant cost savings. Yet such potential cannot be realized without greater consumer access to price, quality and treatment information. This article describes why consumer-based strategies have taken hold and how consumer-driven plan design and financial incentives are of only limited value in controlling costs. After reviewing the importance and availability of existing health care information, the authors suggest actions employers can take to ensure consumer-driven plans reach their potential.     

Erklärungsansätze für vertragswidriges Verhalten Versicherungsnehmern aus Sicht der ökonomischen Theorie

The two main purposes of this paper are an introduction to the economic analysis of insurance fraud and furthermore a derivation of factors that determine fraudulent behavior of policyholders on insurance markets. Consequently, we analyze the strategic decision problems of insurance companies and the policyholders and identify some factors that can help to reduce fraudulent behavior. In this context we evaluate two derived starting points for the combat against insurance fraud: fraud detection systems and a consequent charge policy of detected defrauders. We illustrate that both points can help to reduce the cost of fraud. Furthermore, we enhance our earlier analysis with respect to the empirical fact that some individuals care about fairness or — in the insurance fraud context — the legitimacy of their actions. Surprisingly, in some market situations these concerns of some policyholders do not lead to a lower fraud probability. Finally, we discuss how and to what extent insurance companies can influence such ethical concerns of policyholders. On that score, we distinguish insurance specific and insurance unspecific factors and their impact on the consumers attitudes towards insurance fraud.     

Consumer-driven health plans: design features to promote quality improvement

The most prevalent form of consumer-driven health plans (CDHPs) presents risks in terms of the cost, quality and appropriate use of health care. This article identifies those risks and shows employers how they can reduce them without compromising the overall cost-control potential of CDHPs. A good CDHP strategy should work on both the demand and supply sides of the market.     

What states are doing to control health insurance costs

Like other employers, state governments are struggling with continued health care cost increases. A 50-state survey reveals that these large public employers are actively attempting to control the cost of their plans while ensuring quality and a commitment to their employees' overall good health.     

Measuring Selection Incentives in Managed Care: Evidence From the Massachusetts State Employee Insurance Program

Capitation gives insurers incentive to manipulate their offerings to attract the healthy and deter the sick. We calculate the incentives for such service-specific quality distortions using managed care medical and pharmacy spending data for fiscal years 2001 and 2002 from the Massachusetts State Employee Insurance Program. Services most vulnerable to stinting are cardiac care, diabetes care, and mental health and substance abuse services. Empirically, the financial temptation to distort service quality increases nonlinearly with supply-side cost sharing. Our empirical results highlight how selection incentives work at cross-purposes with efforts to reward excellent chronic disease management. Initiatives coupling pay-for-performance with risk adjustment and mixed payment hold promise for aligning incentives with quality improvement.     

Redefining competition in health care

The U.S. health care system is in bad shape. Medical services are restricted or rationed, many patients receive poor care, and high rates of preventable medical error persist. There are wide and inexplicable differences in costs and quality among providers and across geographic areas. In well-functioning competitive markets--think computers, mobile communications, and banking--these outcomes would be inconceivable. In health care, these results are intolerable, with life and quality of life at stake. Competition in health care needs to change, say the authors. It currently operates at the wrong level. Payers, health plans, providers, physicians, and others in the system wrangle over the wrong things, in the wrong locations, and at the wrong times. System participants divide value instead of creating it. (And in some instances, they destroy it.) They shift costs onto one another, restrict access to care, stifle innovation, and hoard information--all without truly benefiting patients. This form of zero-sum competition must end, the authors argue, and must be replaced by competition at the level of preventing, diagnosing, and treating individual conditions and diseases. Among the authors' well-researched recommendations for reform: Standardized information about individual diseases and treatments should be collected and disseminated widely so patients can make informed choices about their care. Payers, providers, and health plans should establish transparent billing and pricing mechanisms to reduce cost shifting, confusion, pricing discrimination, and other inefficiencies in the system. And health care providers should be experts in certain conditions and treatments rather than try to be all things to all people. U.S. employers can also play a big role in reform by changing how they manage their health benefits.     

Integrating benefits decision making

Integrated employee benefit decision making helps employees use their benefits more wisely and identify opportunities to balance their immediate benefits needs (such as health care) and future benefits needs (such as retirement). This article discusses how employers can overcome employees' behavioral barriers to making integrated employee benefit decisions by changing the ways benefits are communicated and employees are presented with action decisions. Undertaking these steps allows employers to not only improve their employees' overall financial perspectives, but also furthers plan sponsors' goals of actively promoting personal responsibility with respect to retirement funding and changing employee behavior with respect to controlling health care costs.     

Will disruptive innovations cure health care?

It's no secret that health care delivery is convoluted, expensive, and often deeply dissatisfying to consumers. But what is less obvious is that a way out of this crisis exists. Simpler alternatives to expensive care are already here--everything from $5 eyeglasses that people can use to correct their own vision to angioplasty instead of open-heart surgery. Just as the PC replaced the mainframe and the telephone replaced the telegraph operator, disruptive innovations are changing the landscape of health care. Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions--teaching hospitals, medical schools, insurance companies, and managed care facilities--are fighting these innovations tooth and nail. Instead of embracing change, they're turning the thumbscrews on their old processes--laying off workers, delaying payments, merging, and adding layers of overhead workers. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seeds of its own destruction. The history of disruptive innovations tells us that incumbent institutions will be replaced with ones whose business models are appropriate to the new technologies and markets. Instead of working to preserve the existing systems, regulators, physicians, and pharmaceutical companies need to ask how they can enable more disruptive innovations to emerge. If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone.     

Health and the welfare of U.S. business

Business leaders continue to blame the skyrocketing cost of health care for jeopardizing the global competitiveness of U.S. industries, and they continue to turn to Washington for the solution. Yet after a study of 16 countries, Wharton researchers David Brailer and R. Lawrence Van Horn have discovered that health care costs do not directly hinder U.S. competitiveness. Their conclusion: there is indeed a health care crisis in the United States as well as a competitiveness crisis. But the two are unrelated, and confusing them makes it difficult to solve either one. The real problem, according to the authors, is the hands-off approach that employers typically adopt when it comes to health care. No matter how Washington responds to the health care crisis, employers must explore their own role in ensuring the health of their work force. And they must realize that their role can be a strategic one. Instead of containing costs by fine-tuning benefits packages, companies can control costs and improve health care delivery by treating health care like any other crucial component of production. Brailer and Van Horn propose three strategies for managing health care delivery: First, companies must intervene in the supply side of the health care market. This may mean creating a clinic alone or with other companies, or joining with other companies to procure health care. Second, companies need to translate corporate health benefits into the most cost-effective set of services at the local level. Finally, companies must encourage and educate employees to participate in decisions regarding health care delivery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Health care consumerism: engaging the real buyers--employees

Many employers have begun moving toward health care consumerism strategies designed to encourage employees to take more responsibility for their health care and the cost of that care. Recent surveys suggest ways employers can ensure their consumerism strategies succeed in engaging employees and, ultimately, encourage employees to change their behavior. This article describes what those surveys reveal about employer and employee perspectives on consumerism and suggests steps employers can take to align their interests with those of their employees in order to manage the demand for and use of health care.     

Hospital Costing: Experience from the VHA

The government administered Veterans Health Administration (VHA) is the largest integrated health care system in the USA. As health care dollars are becoming tighter nationwide, VHA faces the dual challenge of achieving cost reductions and improving quality, while operating in an increasingly competitive marketplace. This places new demands on cost accountability within the agency. This paper identifies the cost accounting procedures currently used by VHA as it responds to internal budgetary curtailment and to external competitive pressures. Understanding the different costing approaches taken by the organization along with their associated problems offers lessons of interest to financial managers within and outside VHA.     

Health systems futures: The challenges of technology,prevention and insurance

This article argues that the futures of health systems depend on how countries address three wider challenges that include: (a) the adoption of health innovations and quality improvements, (b) responses to new non-communicable and preventable global diseases, as well as (c) adjusting financial models to current insurance constraints. Future trends point towards an increasing dependence on productive quality improvements, the personalisation of health care and the organisation of delivery and finance to take advantage of existing knowledge. Prevention, and disease avoidance, particularly that of non-communicable diseases, will aim to reduce pressure on “care components” of the health system whilst global control of communicable risks will become apparent. Finally, trends suggest an increase in patient participation and personalisation of insurance contracts will help to realign risk sharing with cost containment and financial sustainability. Other potential challenges such as ageing are regarded as second order issues to be addressed through these aforementioned future trends.     

The role of the PBM in total health management strategies for individuals with chronic conditions

In this article, we examine the multiple data sources and outcomes surrounding the management of both pharmacy and medical cost spending for chronic health care in one pharmacy benefit manager (PBM). We offer examples of how the complex relationship between interventions and spending is utilized in order to bring value to PBMs' clients above and beyond the scope of traditional pharmacy trend analytics. Additionally, we demonstrate how the implementation of disease management programs can effectively impact the largest component of total health care costs.     

Making competition in health care work

Health care reform in the United States is on a collision course with economic reality. Most proposals focus on measures that will produce one-time cost savings by eliminating waste and inefficiency. But the right question to ask is how to achieve dramatic and sustained cost reductions over time. What will it take to foster entirely new approaches to disease prevention and treatment, whole new ways to deliver services, and more cost-effective facilities? The answer lies in the powerful lessons business has learned over the past two decades about the imperatives of competition. In industry after industry, the underlying dynamic is the same: competition compels companies to deliver constantly increasing value to customers. The fundamental driver of this continuous quality improvement and cost reduction is innovation. Without incentives to sustain innovation in health care, short-term cost savings will soon be overwhelmed by the desire to widen access, the growing health needs of an aging population, and the unwillingness of Americans to settle for anything less than the best treatments available. The misguided assumption underlying much of the debate about health care is that technology is the enemy. By assuming that technology drives up costs, reformers neglect the central importance of innovation or, worse yet, attempt to slow its pace. In fact, innovation, driven by rigorous competition, is the key to successful reform.     

Finding a lasting cure for U.S. health care

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”     

Defining the road ahead: thinking strategically in the new era of health care reform

Understanding the implications of the new health care reform legislation, including those provisions that do not take effect for several years, will be critical in developing a successful strategic plan under the new environment of health care reform and avoiding unintended consequences of decisions made without the benefit of long-term thinking. Although this article is not a comprehensive assessment of the challenges and opportunities that exist under health care reform, nor a layout of all of the issues, it looks at some of the key areas in order to demonstrate why employers need to identify critical pathways and the associated risks and benefits of each decision. Key health care reform areas include insurance market reforms, grandfather rules, provisions that have the potential to influence the underlying cost of health care, the individual mandate, the employer mandate (including the free-choice voucher program) and the excise tax on high-cost plans.     

Prospects for account-based health plans under the Patient Protection and Affordable Care Act

Account-based health plans (ABHPs), which combine high-deductible plans with either health reimbursement arrangements (HRAs) or health savings accounts (HSAs), have gained popularity in recent years. Because there is growing evidence these plans are indeed engaging consumers and moderating cost increases, employers will need ABHP design options as they strive to bring costs under control in coming years. Some observers, however, are now concerned that benefits standards introduced by federal health care reform will undermine these plans, and many in the business community anticipate new health benefits mandates will drive up employers' total health care costs. The authors show that although the Patient Protection and Affordable Care Act (PPACA) of 2010 includes numerous provisions that will likely increase costs for employers, the law also accommodates, and may even foster, HSAs and HRAs.     

The history of employment-based health insurance: the role of managed care

The author describes the history of how the employment-based health benefits system has evolved. Specifically, he examines how we got where we are today, the success of managed care, the shortcomings of the managed care system and challenges that the managed care system will face in the future. He concludes that, despite substantial improvements in the quality of medical services provided, employers have a long way to go before they are truly purchasing the highest quality health care at the most efficient prices.