A World Without Health Insurance Companies?

July 9, 2012

How are your payers performing? Current data indicate that payer performance is declining. Here's what you can do to maximize your reimbursement.

How are your payers performing? How often do they pay exactly what they owe you, on time, with as little fuss as possible?

These questions have plagued practices since the dawn of managed care, mainly because getting an answer can be such a chore, what with dozens of payers overseeing hundreds of health plans, each with its own unique set of rules and fee schedules. The annual PayerView rankings - from national billing and practice-management services company athenahealth - is a valuable addition to your limited arsenal of tools for evaluating payers. PayerView grades insurers on how well they work with practices by using real data gleaned from millions of claims run through its network. We've been proud to partner with athenahealth since 2006, providing you access to the extensive data and analysis of what it all means.

PayerView has been a success story, shedding a light on payer inefficiencies and driving improvements in their performance every year - until this year, that is.

Maybe the payers are devoting so much energy to meeting new government regulations that they've allowed their day-to-day performance to slip. Or maybe their performance just peaked last year, and we'll now start seeing year-to-year ups and downs. Whatever the reason, PayerView's latest data shows an overall performance decline for the first time. Joe Hendrickson, vice president of athenaNet, which compiles the PayerView rankings, noted that even as payers are getting worse at paying what they owe you, they're also transferring more of what you're owed to patients, who are far more difficult to collect from. The only good news, really, is that the decline in payer performance is pretty modest in most cases.

But this year, another, even more ominous question lurks: Does payer performance really make a difference anymore? In an accountable-care-focused healthcare world, where global, bundled payment for holistic care is supposed to replace the fee-for-service model, who cares about Aetna's denial rate or UnitedHealthcare's performance on quick claims resolution? Aren't we moving to a world without payers?

Many people think the end of private health insurance is nigh. Ezekiel Emanuel, a well-known healthcare policy analyst and former adviser to President Obama, predicted its end in the New York Times. No less an authority than Aetna chief Mark Bertolini caused a great stir when he told an audience at a large trade show in February "the end of insurance companies, the way we've run the business in the past, is here."

I'm skeptical. Massachusetts' health reform, now six years old, did not spell the end of Bay State health insurers. Aetna's stock was still trading at $41 a share in mid-June. I'm not sure the Affordable Care Act will kill insurance.

But the argument is that the ACA's elimination of medical underwriting means insurers can't manage risk, the bread-and-butter of the insurance business. Meanwhile, other regulations and taxes are combining to make health insurance unprofitable. And while the ACA set the insurance industry on its mortal path, a rollback of the law by the Supreme Court, which had not yet released its decision at this writing, wouldn't be enough to save payers. It's too late.

So goes the theory. Now here's the question: If the payers are doomed, isn't that all to the good, or will we miss them when they're gone? Will the payment mechanism that replaces the payers, whatever form it takes, be better - for, you, that is - than the status quo? Or do you prefer the devil you know?

Bob Keaveney is the editorial director of Physicians Practice. Tell him what you think at bob.keaveney@ubm.com or on Facebook: http://on.fb.me/dRZmgJ. Unless you say otherwise, we'll assume that we're free to publish your comments in upcoming issues of Physicians Practice, in print and online.