WHY THE HEALTH CARE MARKETPLACE IN WISCONSIN IS BEHIND 5 TO 10 YEARS IN INNOVATION OF RISK MANAGEMENT SOLUTIONS. BELIEVE IT?

Why the Wisconsin HEALTH CARE BENEFITS marketplace, particularly the SE Wisconsin health care benefits marketplace is behind by 5 to 10 years. Believe it? Hello again. No this is not a rant like some of my other articles, but it does tend to "slice a bit deep" as to the evolution of the health care benefits marketplace in Wisconsin.  

Here's a few questions that we'll begin with, so that you gain a flavor for my commentary:

1) Do you believe that the Wisconsin health care benefits marketplace has broadened or become more restrictive since 2010?

2) Do you agree that a 4.5%-5% increase in pricing at the hospital provider system level each year over 10 years combined with the PPACA impact equals a 50% to 75% change in cost and pricing?

3) Do you believe, and or agree, that the health care benefit economic front in the state of Wisconsin has reach a point of crisis on two terms: A) Employer Affordability and B) Employee out of pocket cost?

4) Do you believe, and or agree, that as an employer your options in terms of innovative choices as to providing your employees affordable health plan options has become a major issue for your company? 

5) Are you tired of, or or frustrated, with the lack of innovative, and or creative, risk management solutions that are presented to you each year as health benefit plan benefit options for your employees?

If you answered "Yes" to some of or even all of the above questions, then the following commentary will make sense to you. Let's begin with a list of economic events that have changed the health care economic landscape in Wisconsin over the past decade or so:

* Sunset of the Certificate of Need law. Removed the Certificate of Need Board from regulating the building and expansion of health care facilities in the state of Wisconsin.

* The 15 year evergreen agreement between one of the state's largest health insurance companies and one of the largest provider systems in the state of Wisconsin.

* The growth of, and expansion of health care provider systems, that dramatically reduced the number of health care providers in the state of Wisconsin. The key term being "systemization" of health care providers in the state to where nearly $.90 of every dollar spent in health care is through one of 4 systems in the state. Also, the reduction of independent primary care physicians to where 85%+ are "owned" by one of those systems.

* The proprietary agreements between three of the largest health insurance companies in the state of Wisconsin and the large provider systems that have evolved as mentioned above.

* The proprietary agreements between the large health insurance carriers and the major brokerage firms in the state of the Wisconsin.

* The proprietary system of reimbursements to brokers by the large insurance carrier(s) in the state of Wisconsin, that "bonus" brokerage houses for the amount of business, both fully insured and self-funded, that the brokerage houses sell and maintain with these certain carriers. The "bonuses" are NOT related to any fees or commissions paid to brokerage firms by the employer or through the employer's payments to the carrier. They are simply bonuses, sometimes in the 6-zero realm, for the size of the block of business that is kept with the carrier.

* The passage of the PPACA law that included provisions of mandated benefits and the ACO law. The PPACA law also include mandatory fees paid by employers back to the government for each employee covered under a health plan. Many employers still do not understand the estimated cost of the mandated benefits, 15%-20%, that has been passed onto their health plan cost by the law. The ACO provision essentially allows provider systems to coordinate, merger, "systemize" without fear of confronting monopolistic legal issues. This means that the evolving systemization, the bigger provider systems getting bigger and the small independent hospital providers being assumed by the bigger ones, will continue.

If you consider the impact of all of the above as part of the evolution of the current health care economic landscape in the state of Wisconsin, it provides foundational evidence as to why competition has actually been reduced and restricted. It also provides foundational evidence as to why, particularly for groups who continued to be fully insured, their premium costs have increased as dramatically as they have. Back when the PPACA law was first passed, did you ever think that family plan costs, according to the latest Kaiser reports, would reach $20,000+ a year in the state of Wisconsin? How about fully insured family premium rates exceeding $2000 a month? Do you or do you now "trust" any longer the statements made to you by brokers and insurance carriers that they continue to have the "deepest network discounts" available? How often do you think, when that statement is made to you, "Discount off of what?" When you are enlightened to the fact that service pricing for health care services delivered have reached, in some cases, in excess of 500% of what Medicare pays for the same service, doesn't that make you wonder, really, "discount off of what? While there have been a number of innovations, or "inventive" ideas and options, developed in the health benefits marketplace to address this health care cost crisis, such as: RBP, Bundled pricing, advanced DRG pricing, discussions as to "episode of care" pricing, the resistance by the players in the health care benefits marketplace have all been resistant to such advancements. One insurance company that does primarily group coverage for employers under 100 lives has implemented total RBP pricing, however, the overall resistance has been a stalwart to the innovation and creation of new risk management techniques that actually drive cost down. Many employers have actually given up on the idea that wellness initiatives have any impact what-so-ever on their overall health plan cost. Why? Because it's still increases at a low of 5% to almost 10% annually. Since the implementation of the PPACA "no lifetime maximums" on benefits, the trend line on $1,000,000 claims has achieved a trend (depending on the carrier or re-insurance carrier) of 40%-60%. Added to this is the development and creation of bio-tech drugs that have reached an annual price of more than most of us would pay for a home and in some cases a home and a car in Wisconsin. A few examples, current and coming are: Kymriah-$475K annually; Yescarta-$373K annually; Luxturna-$850K annually; and Zolgensma-$2.1M annually-as well as a number of others. Once again, do you agree or disagree, that all of this has taken us to the point of crisis in the state of Wisconsin?

My last question to you all is as follows: Think about this one-Who is it, and and who are they, that benefit from what has evolved and taken place in the health care benefit economic landscape over the past 10 years or so? Have any of them done anything, really, to help employers come to a reasonable solution to actually bring health care cost back to being reasonable and bring employee out of pocket cost back to being reasonable?

Okay, here's my pitch-ready? Under the approval, and auspicious of The Starr Group, I have been allowed to developed advanced health care models that do the following:

1-For the first time, build accountability between the employee and the employer in the employer's sponsored health care benefit plan.

2-Enlightened employers as to the facts rather than myths regarding self-funding vs: being fully insured.

3-Developed models, proprietary, that totally integrate wellness initiatives into an employer's benefit plan so that Wellness has an UP FRONT ROI-NOT, IF YOU DO THIS IT MAY SAVE YOU X. What really is X?

4-Developed models that actually give the employee more for less, but deliver cost savings to the employer.

5-Help, teach, and guide the employer to understand the risk management ramp so they can actually gain control of their health benefit plan as well as dramatically change their health care culture, AND, execute population management as well.

Want to know more: Contact one of our consultants at The Starr Group and ask them about WellBen Dynamic Medical Home or Engage Cafe-both trademarked proprietary models. We can also talk to you about how DPC's can save you and your employees a lot of money as well as provide your employees with a quality level of primary care.

If you want to change what is happening, you can't continue to do the same old thing. These models are advanced from an underwriting standpoint and have proven service partners who deliver the highest quality level of service to you and your employees .

Want to talk about the risk management ramp-the cost of human capital-how the risk management tools we've developed once executed can impact the future "trend direction" of, and actually "gain control," of the risk of your health care benefit plan?

If you're an employer of 50 employees or more on your plan-call us-let's talk innovation, let's talk new, let's talk something different than the same old same old-Ready? We are. The Starr Group Benefit Risk Management Consulting Team-414-421-3800

Thanks-Greg