Category: Health plans

The healthcare cost revolution will not be televised either

published date
November 6th, 2019 by
protest 155927 1280
Coming to a TV near you

The quote at the end of yesterday’s Boston Globe article (Consumers struggle to find information on health care costs, poll shows) made me laugh.

“We’re seeing more and more consumer awareness every year,” [an insurance executive] told the Globe. “It’s a revolution that’s occurring, but it occurs over time.”

When I read about this ‘revolution’ it brought to mind an expression/poem/song from long ago: The Revolution Will Not Be Televised! The timeframe for the healthcare cost ‘revolution’ is on the order of decades, and I don’t think anyone will be able to sit still for a TV show of that length!

Not surprisingly, the Pioneer Institute’s survey demonstrated that while people with commercial insurance are interested in obtaining  price information before receiving a healthcare service, they don’t often get it. Only 2 to 7 percent of people check costs on insurers’ websites, according to the Attorney General.

Although that number seems crazily low, it’s actually easy to understand once you consider the multitude of the barriers:

  1. Patients don’t know what services they’re going to need
  2. Choice of provider often trumps cost as a factor
  3. Their health plans may not reward or punish them for saving or spending more money
  4. Next year’s insurance premiums are unaffected by what they do this year
  5. Those with a high deductible plan are likely to blow through the deductible anyway if they have serious medical expenses
  6. Insurers’ cost estimators aren’t easy to use
  7. The estimates may not be accurate anyway
  8. People haven’t heard about the available tools

I’m an educated consumer with a high deductible plan but I don’t try to check the costs ahead of time.

So there’s no need to be glued to your TV (or other device) watching this ‘revolution.’


By healthcare business consultant David E. Williams, president of Health Business Group.

Blockbuster Medicare Innovations: AHIP panel recap

published date
September 27th, 2019 by

I enjoyed moderating the Blockbuster Medicare Innovations panel at the AHIP conference on Medicare, Medicaid and Dual Eligibles. In this video recap, I summarize the panelists’ key takeaways on supplemental benefits, home dialysis, and telemedicine.

Thanks to Dr. Michael Cantor of CareCentrix, Bruce Greenstein of LHC Group and Mary Hsieh PharmD MPH of Health Management Associates for doing a great job with it.


By healthcare business consultant David E. Williams, president of Health Business Group.

Harvard Pilgrim and Tufts are merging. Here’s why it doesn’t really matter

published date
August 15th, 2019 by
Hail to the Chief! Tom Croswell is slated to lead the combined Tufts/Harvard health plan

Harvard Pilgrim and Tufts –the second and third largest health plans in Massachusetts–  are merging.  It deserves the front page treatment it’s receiving today (check out the comprehensive coverage in the Boston Globe) –and will have an impact on employees and members– but I predict that the long term impact on Massachusetts healthcare overall will be modest at best.

To boil it down, despite being ranked by NCQA as the top two health plans in the whole country for many years (here’s 2014 for example), it’s been a long time since either Harvard or Tufts had a major influence in the local market. That’s harsh but I don’t think I’m overstating things.

In 2001 when I was setting up my business and looking for health insurance, I asked around about which insurer to use. My doctors said they were indifferent, but a friend at Partners Health Care told me Blue Cross was the only plan they paid attention to.

The last time Tufts tried to seriously impact the market was about 20 years ago, when Partners HealthCare manhandled them in rate negotiations.  And former Harvard Pilgrim CEO, Charlie Baker admitted publicly around the early aughts that when Harvard Pilgrim tried innovative reimbursement structures, hospitals just ignored them and converted everything into Medicare equivalents. And clearly the attempt to channel volume to community hospitals and away from Partners was a bust.

At least in Baker’s current job as Governor he has some influence.

I don’t mean to be cynical at all. I’ve followed both of these mission-driven companies for many years and would love the new combined entity to be an influential innovator –not just in holding down costs but in radically improving experience and quality as well.

But after so many years of banging their heads against the wall, will they give it another go? I kind of doubt it. As the number 2 player in an insurance market led by Blue Cross Blue Shield, and a healthcare market dominated at the Massachusetts level by Partners and BI/Lahey and overall by the federal and state governments, I see their role mainly around the margins. I’m not sure their leadership is ready to go all out to change the system either.

In the last several years, under CEO Andrew Dreyfus, Blue Cross has actually passed Harvard Pilgrim and Tufts in the NCQA ratings. It’s been more innovative as well, with the Alternative Quality Contract (AQC) in particular.

I looked back this morning at my blog coverage of these companies over the years and picked out some highlights.

I’ve interviewed the CEOs of all three:

  • Tom Croswell, who will head the combined entity and is currently CEO of Tufts (2018)
  • Eric Schultz, then CEO of Harvard Pilgrim in a four-part video series in 2011 and again in a podcast in 2013
  • Charlie Baker, when he was running for Governor in 2014. (I interviewed every candidate that year)
  • Andrew Dreyfus, CEO of Blue Cross Blue Shield in 2012

In my coverage (which is by no means comprehensive) I found a few examples of Harvard Pilgrim and Tufts trying to make waves in the market.

There’s much more to say, of course, but I do wish the new entity luck! Massachusetts can use all the help it can get.


By healthcare business consultant David E. Williams, president of Health Business Group.

Remedy Partners founder Steve Wiggins explains why he’s high on bundled payments (podcast)

published date
April 29th, 2019 by
Wiggins Steve P1210186 Edit 1
Remedy Partners founder Steve Wiggins

Steve Wiggins has seen a thing or two in his more than three decades as a healthcare entrepreneur. His Oxford Health Plans introduced “pods,” a precursor of the Accountable Care Organization and he led HealthMarket, an early player in the consumer directed health plan space. He’s carried the same themes into his current  role as founder and Chairman of Remedy Partners, the leader in Medicare’s Bundled Payments for Care Initiative (BPCI).

As you’ll hear in this podcast, Steve’s a big believer in bundles, offering them as a proven solution for a large portion of the healthcare dollar, within almost any healthcare financing framework from traditional commercial coverage to Medicare for All.

Here’s what we discussed:

  • (0:18) What is a bundled payment? How does it relate to other new approaches like ACOs?
  • (3:05) Did bundled payments start in Medicare rather than the private sector? If so, why?
  • (6:52) How well has BPCI worked? What does the future look like?
  • (11:01) How do episodes and bundles tie in more broadly? I often hear that chronic care or end of life care are the big cost drivers, not episodic care. Can those statements be reconciled?
  • (15:10) How should we think about bundled payments and related topics playing into the campaign, or should we just give up on that?
  • (19:14) You’ve founded quite a few healthcare companies over your career. How does this Remedy compare?
  • (21:41) How do you expect the company to evolve in the next few years?

By healthcare business consultant David E. Williams, president of Health Business Group.

Medicaid Buy-In: A sensible approach for coverage and cost

published date
January 23rd, 2019 by
health insurance 2574809 1280
Show me the coverage!

The term ‘Medicare for All’ is being bandied about as the campaign for the Democratic Presidential nomination gets underway. Declared and potential candidates are warming to the idea.

It’s easy to see why:

  • After years of trying to defend complex, compromised Obamacare from GOP rhetorical attacks and legislative and administrative undermining, Democrats are going with a program that is popular and well funded
  • Medicare especially appeals to the middle-aged and older population, who tend to vote. There’s no stigma attached to it
  • It could be funded and implemented as a sweeping program at the federal level, which is ideal for a Presidential candidate to talk about.

However, I’d much rather see attention turn to continued expansion of Medicaid, specifically by offering people the opportunity to “buy in” to Medicaid coverage. This has real advantages:

  • It’s the prices stupid,” we have been told since 2003. Price, not utilization, is the main reason the US spends so much more than other countries. By design, Medicaid puts the squeeze on costs through lower reimbursement rates
  • Medicaid has provisions to squeeze drug prices, too, something Democrats and Republicans favor
  • Medicaid coverage is more holistic than Medicare. It includes programs to address social determinants of health, and is suitable for younger people including parents and children
  • Medicaid is a partnership between the states and federal government, enabling individual states to craft solutions that fit their specific populations

Several states are already looking at Medicaid expansion as a way to address their specific issues. For example, New Mexico (a purple state) is getting serious about further use of Medicaid. The state has some distinctive characteristics:

  • Medicaid is by far the largest player already, covering 40% of the population
  • The uninsurance rate remains stubbornly high at 9%
  • There are many undocumented and mixed status families who are shut out of the current coverage system

New Mexico is studying four approaches. (You can read the assessment here.)

  1. Targeted Medicaid buy-in: Medicaid-style coverage to those ineligible for Medicaid, Medicare, or the Obamacare marketplace. The state would subsidize premium costs
  2. Qualified health plan public option: A variant on the program originally proposed in Obamacare, with coverage on the marketplace in partnership with an insurer
  3. Basic Health Program: An Obamacare option already
  4. Medicaid buy-in for all: An off-marketplace program available to anyone except Medicare eligibles

The analysis leads me to the idea of starting with Option 1 as a trial run for Option 4. The advantage of Option 1 is that it doesn’t require federal approval, would bring uninsured people into the system who are currently discriminated against, and provide a test bed for further expansion. It would not disrupt the current market by drawing away healthy people, because it is only open to those currently outside the system.

Option 4 could come into force after the 2020 election, when the federal environment is more favorable and once New Mexico has learned from its initial experience.

Sometime down the road, an even more radical version would shift everyone into Medicaid. Private health plans would still have a role since everyone could be enrolled in Medicaid managed care. Providers and drugmakers won’t like the compressed reimbursement, but maybe it will encourage them to innovate on efficiency.

All of these proposals can be combined with value based approaches, which enable the efficient, high quality providers to succeed while containing costs and potentially boosting the patient experience and outcomes.

For now, I’d like to see the debate start up as part of the presidential race. Candidates visiting early primary and caucus states should dig in. In Iowa, for example, Medicaid for all is being discussed by local Democrats.

By healthcare business consultant David E. Williams, president of Health Business Group.