Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest C om m e n ta r y 128 BALANCE SHEET this inequitable, inflationary provision at the behest of private employers, which found the arrangement helpful in their quest to make their workers accept more overt

Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest C om m e n ta r y 128 BALANCE SHEET this inequitable, inflationary provision at the behest of private employers, which found the arrangement helpful in their quest to make their workers accept more overt cost sharing for their health care. n Lack of choice. Whatever benefits employees derive from the current paternalistic system, one price they pay is limits on their choices in the health insurance market. As Stan Jones, Lynn Etheredge, and Larry Lewin reported in 1996, close to half of American employees are offered only one health plan by their employers. 6 They are in what one may call a private single-payer system. Another quarter or so of employees are offered a choice of only two health plans. A more recent Kaiser/Commonwealth national survey of health insurance corroborates these estimates.7 This lack of choice makes a mockery of the idea of “managed competition.” n Lack of privacy. In many instances, the employer-based system gives private employers access to their employees’ medical records.8 It is one thing to know that a private insurance carrier has information on the most intimate details of one’s life. It is quite another to think that the personnel department of one’s employer can get access to that information as well. Whatever one may think about health systems abroad, patients in those countries do not worry about this invasion of privacy. n Administrative complexity. The defenders of employer-based health insurance tend to view it as more “efficient” than alternative arrangements. That proposition is incredible, given the current system’s administrative complexity. Exhibit 1 illustrates this point. The data there are the fruits of a multiyear study by McKinsey and Company of the American and German health systems, the latter of which is based on private, not-for-profit sickness funds that operate within a tight statutory framework.9 The McKinsey research team concluded that the U.S. system is more productively efficient than Germany’s system is. It based that conclusion on the finding that in EX HIB IT 1 Decomposition Of Differential Per Capita Health Spending In Germany And The United States, 1990 Per capita spending in Germany Less use of real medical inputs in the United States Plus higher prices in the United States Plus higher administrative costs in the United States Plus “other” higher costs in the United States Total additional costs per capita in the United States Per capita spending in the United States SOURCE: McKinsey Global Institute (1996), Exhibit 5. a Purchasing power parity. $1,473 –390 737 360 259 966 2,439 100.0% –26.5 50.0 24.4 17.6 65.6 165.6 H E A L T H A F F A I R S ~ V o l u m e 1 8 , N u m b e r 6 Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest I N S U R A N C E B A L A N C E S H E E T “If properly managed competition is ever to develop in this country, chances are that Medicare will have to lead the way.” 1990 Germans actually spent $390 more per capita on strictly medical inputs (hospital days, physician visits, drugs, and the like) than did Americans. As the exhibit shows, however, the U.S. system burned up more than the entire savings from its allegedly superior clinical productivity on higher administrative expenses ($360 per capita) and on higher outlays on the catch-all category “other” ($259). Because Medicare and Medicaid are known to spend relatively little on administration, the higher U.S. figure must reflect mainly private insurance. Given that the U.S. system outranks no other system in the industrialized world in either measured health status indicators or patient satisfaction , it can fairly be asked: In what sense is employer-based health insurance “efficient”? n Lack of transparency. Standard economic theory and empirical research have convinced economists that the premiums paid by employers on behalf of employees are merely part of the total price of labor and, over the longer run, are shifted back to employees collectively through commensurate reductions in take-home pay. Unfortunately, it is not known precisely how employers do this. That may be why employees typically assume that their employer fully absorbs the part of the premium that is not explicitly deducted from their paycheck. Unaware of how much their health insurance actually costs them in terms of forgone take-home pay, employed Americans have never showed nearly enough self- interest in health care cost containment. This may explain why over the long run the employer-based system has so frequently acted as the inflationary locomotive in American health care. COMMENTARY 129 Ambiguous Entries To my mind, the previous entries were clear-cut debits or credits. There remain a number of items whose proper entry into the employer-based system’s account is more ambiguous. n Health spending. It seems to be widely taken as an axiom that private health insurers are always more successful than the public sector is at cost control in health care. This hypothesis does find support in the period 1992–1997, when the national average of the health insurance premiums paid under the employer-based system did rise less rapidly than per capita health spending in the public sector. Therefore, one might be tempted to credit the employerbased system with superior cost control. H E A L T H A F F A I R S ~ N o v e m b e r / D e c e m b e r 1 9 9 9 Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest C om m e n ta r y 130 BALANCE SHEET As is well known among analysts familiar with the national health accounts, however, the private insurance sector has not consistently outperformed the public sector in this regard. For example, during most of the 1980s premiums in the private sector rose much more rapidly than did Medicare spending per enrollee. That is true again today and for the foreseeable future. From a long-run perspective, the fairest statement is that in some periods the private insurance sector seems more able to control the growth of health spending, while in other periods the public sector has been more successful. n Managed competition. At the beginning of the decade Americans looked to employer-based health insurance as the spearhead of “managed competition.” That arrangement requires individual households to choose from a menu of rival health plans the one plan that will subsequently regulate (manage) the health care received by family members in case of illness. Such a daunting choice presupposes an information infrastructure capable of informing households about (1) the manner in which the rival health plans regulate health care in case of illness, and (2) the quality of the services rendered by the providers of health care with which the health plans contract for services. Only a few employers provide workers with such information. Even the roughly 50 percent of Americans whose employer actually does offer them a choice among health plans are given only sketchy information on the plans and usually none on the quality of the providers of health care associated with them. For example, in the HMO Performance Report of the 1997 Benefits Decision Workbook for its New Jersey employees, the Xerox Corporation, which is generally thought of as one of the most sophisticated buyers of health insurance, noted that neither the Oxford Health Plan nor its competitor, U.S. Healthcare, permitted dissemination of a variety of crucial performance data to Xerox employees, including the board certifications of physicians and enrollee satisfaction .10 As Etheredge has concluded (and I concur), if properly managed competition is ever to develop in this country, chances are that Medicare will have to lead the way.11 n The NCQA. The employer-based system can claim credit for having created jointly with the managed care industry the National Committee for Quality Assurance (NCQA), which in turn has developed the Health Plan Employer Data and Information Set (HEDIS). HEDIS certainly represents a major contribution to the science of measuring and monitoring the quality in health care. The NCQA has contributed further to quality control through its accreditation of health plans. H E A L T H A F F A I R S ~ V o l u m e 1 8 , N u m b e r 6 Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest I N S U R A N C E B A L A N C E S H E E T Remarkably, however, a national survey in 1997 revealed that only 9 percent of employers made NCQA accreditation a requirement for including a health plan on their offering to employees. Only 1 percent of employers provides HEDIS data to employees to assist them in plan selection.12 Although interest in the data may have grown since that survey, this sluggish uptake by employers speaks poorly of the entire enterprise. Perhaps the intended users of the HEDIS data question their validity, because the modus operandi of the NCQA represents a classic application of Nobel-laureate economist George Stigler’s now famous “capture theory.” According to that theory, those who are to be regulated by a public body eventually capture the regulatory apparatus. Because the NCQA started as a joint effort between employers and health plans, a certain degree of capture by the health plans was guaranteed at the outset. Not surprisingly, then, participation in the NCQA has remained voluntary on the part of health plans. Furthermore, plans that do submit data to the NCQA can prohibit their dissemination to the public. Finally, all of the HEDIS data, including those on enrollee satisfaction , are self-reported by plans rather than retrieved by a process not under plans’ control.13 At the very least, employers should have formed and funded a coalition that surveys enrolled consumers externally.14 One could debate whether, on balance, the NCQA has been a catalyst or a hindrance in the evolution of managed competition so far. Sometimes a half-hearted effort is worse than none, because its presence precludes or retards the development of superior approaches. In any event, it is not clear how much if any credit is due the employer-based system for establishing the NCQA’s halfhearted effort at quality control. COMMENTARY 131 A lt ho ug h di ff er e nt e va lu at o rs may come up with different debits, credits, and account balances for the employerbased health insurance system, I conclude from the exercise that the debits outweigh the credits. This conclusion does not call for the outright abolition of the current system, but it does suggest the need for a parallel system that would be detached from the workplace and that might, over time, absorb the bulk of the current system. With a proper regulatory framework, such a parallel system need not be public; it could rely on private insurance as well. H E A L T H A F F A I R S ~ N o v e m b e r / D e c e m b e r 1 9 9 9 Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest C om m e n ta r y NOTES 1. Kaiser/Commonwealth 1997 National Survey of Health Insurance, “Working Families at Risk: Coverage, Access, Costs, and Worries” (8 December 1997), 40. 2. U.E. Reinhardt, “Employer-Based Health Insurance: R.I.P.,” in The Future U.S. Healthcare System: Who Will Care for the Uninsured?, ed. S.H. Altman, U.E. Reinhardt, and A.E. Shields (Chicago: Health Administration Press, 1997), 325–352; and U.E. Reinhardt, “Managed Competition: Are Private Employers Up to the Task?” Managing Employee Health Benefits (Winter 1999): 1–9. 3. Hospitalists are physicians who are permanently stationed in a hospital, although they are not the hospital’s employees but could be part of a group practice. 4. J. Gruber and M. Hanratty, “The Labor Market Effects of Introducing National Health Insurance,” Journal of Business and Economic Statistics (April 1995): 163–174. 5. M.V. Pauly et al., “A Plan for ‘Responsible National Health Insurance’,” Health Affairs (Spring 1991): 5–25; and U.E. Reinhardt, “An ‘All-American’ Health Reform Proposal,” Journal of American Health Policy (May/June 1993): 11–17. 6. L. Etheredge, S.B. Jones, and L. Lewin, “What Is Driving Health System Change?” Health Affairs (Winter 1996): 94. 7. Kaiser/Commonwealth 1997 National Survey of Health Insurance. 8. E.E. Schultz, “Medical Data Gathered by Firms Can Prove Less Than Confidential,” Wall Street Journal, 18 May 1994, A1, A5. 9. McKinsey Global Institute, Health Care Productivity (Los Angeles: McKinsey and Company, October 1996). 10. Xerox Corporation, “HMO Performance Report,” 1997 Benefits Decision Workbook (Greenwich, Conn.: Xerox, 1997). 11. L. Etheredge, “The Medicare Reforms of 1997: Headlines You Did Not Read” (Paper presented at a panel on health reform, sponsored by the American Political Science Association, Washington, D.C., 27 September 1997. 12. Commonwealth Fund, “Majority of Employers Do Not Consider Reports on HMO Quality when Choosing Employee Health Plans” (Press release, 15 September 1998). 13. The self-reported data are said to be audited, but little is known about the quality of these audits. 14. S. Williams, “Growing Reliance on Self-Reported HEDIS Data Underscores Need for Auditing,” Medicine and Health Perspectives (18 May 1998). 132 BALANCE SHEET H E A L T H A F F A I R S ~ V o l u m e 1 8 , N u m b e r 6 Downloaded from content.healthaffairs.org by Health Affairs on June 26, 2014 by guest PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT :)